Sarcoma Cancer Diagnosis & Treatment in Singapore
What are Sarcoma Treatments in Singapore?
Presenting treatments for Bone Sarcomas and Soft Tissue Sarcoma subtypes in adults only.
Sarcomas may be treated with surgery, radiation therapy, chemotherapy, targeted therapy, or immunotherapy.
Treatment options and recommendations depend on several factors, including the type and stage of sarcoma, possible side effects, and the patient’s preferences and overall health. Often, a combination of treatments is used to treat sarcoma.
The common forms of therapy for the aforementioned bone sarcomas and soft tissue sarcoma subtypes are described below.
Surgery is the removal of the tumour and some surrounding healthy tissue during an operation. When possible, surgical removal of the tumour should happen after chemotherapy. Surgery may also be needed to remove any remaining cancer cells after chemotherapy or radiation therapy. An orthopaedic oncologist is usually the doctor who will perform the surgery.
Often, a tumour can be removed without causing disability. However, if the tumour occurs in an arm or leg, surgery to remove much of the bone may affect the limb’s ability to function. Bone grafts from other parts of the body may help reconstruct the limb, and a prosthesis made of metal or plastic bones or joints can replace lost tissue. Physical therapy after surgery can help patients learn to use the limb again.
Surgery may also be used to treat bone sarcoma that has spread, or metastasized, to other parts of the body. For instance, surgery can be effective at removing lung metastases, which is where bone sarcomas most often spread.
Bone Sarcomas
- Osteosarcoma Surgery Treatment
Surgery is an important part of treatment for almost all osteosarcomas. The following types of surgery that may be done for Osteosarcoma:
- Wide local excision: This is a surgery to remove the cancer and some healthy tissue around it.
- Limb-sparing surgery: If the tumour is in an arm or leg, techniques to keep the arm or leg intact are used whenever possible. This is sometimes called “limb salvage” or “limb sparing.” However, amputation, which is the removal of the arm or leg with the tumour, is sometimes necessary. This depends on the tumour’s size and/or location.
- Amputation: For some patients, amputation may offer the best option for treating the sarcoma. These include people whose sarcoma is located where it cannot be completely removed by surgery, patients who cannot undergo reconstruction, and patients in whom the surgical area cannot be fully covered with soft tissue. After an amputation, prostheses will be needed.
- Rotationplasty: This is a surgery to remove the tumour and the knee joint. The part of the leg that remains below the knee is then attached to the part of the leg that remains above the knee, with the foot facing backward and the ankle acting as a knee. A prosthesis may then be attached to the foot.
- Ewing Sarcoma Surgery Treatment
After chemotherapy or radiation therapy, cancer that is still present is typically removed surgically. Surgery is used to remove the entire tumour whenever possible. A graft, which uses tissue and bone taken from a donor or another area of the patient’s body, can be used to replace any removed tissue or bone. An implant, such as synthetic bone, may occasionally be used.
- Chondrosarcoma Surgery Treatment
Each patient’s treatment for chondrosarcoma, a rare form of bone cancer, will be different. To get rid of the tumour as much as possible, surgery is used. Cryosurgery is another kind of surgery that uses a cold liquid to destroy the cancerous tissues.
- Giant Cell Tumours Surgery Treatment
Giant cell tumours most often occur in young adults when skeletal bone is complete. Surgery treatments may include:
- Amputation: For some patients, amputation may offer the best option for treating the giant cell tumours. These include people whose sarcoma is located where it cannot be completely removed by surgery, patients who cannot undergo reconstruction, and patients in whom the surgical area cannot be fully covered with soft tissue. After an amputation, prostheses will be needed.
- Bone Grafting: In a surgical process called bone grafting, diseased or damaged bones are repaired and rebuilt using transplanted bone. To perform the graft, the surgeon may use bone from the patient’s ribs, hips, or legs. Additionally, when performing bone grafting, surgeons may use donated cadaveric bone tissue.
- Bone Reconstruction: Bone reconstructive surgery often uses tissue from 1 area of the patient’s body to repair another area. The surgeon will move, or transplant, healthy tissue from another part of your body to the area that needs repair.
Soft Tissue Sarcoma Subtypes
Surgery is the most common treatment for soft tissue sarcoma. It is also the usual treatment for small, low-grade tumours in the trunk, arms or legs. The following types of surgery that may be done for Soft Tissue Sarcomas:
- Mohs Micrographic Surgery: This is a procedure which the tumour is cut from the skin in thin layers. During surgery, the edges of the tumour and each layer of tumour removed are viewed through a microscope to check for cancer cells. Layers continue to be removed until no more cancer cells are seen. This type of surgery removes as little normal tissue as possible and is often used where appearance is important, such as on the skin.
- Wide local excision: This is a surgery to remove the cancer and some healthy tissue around it.
- Limb-sparing surgery: If the tumour is in an arm or leg, techniques to keep the arm or leg intact are used whenever possible. This is sometimes called “limb salvage” or “limb sparing.” However, amputation, which is the removal of the arm or leg with the tumour, is sometimes necessary. This depends on the tumour’s size and/or location.
- Amputation: For some patients, amputation may offer the best option for treating the sarcoma. These include people whose sarcoma is located where it cannot be completely removed by surgery, patients who cannot undergo reconstruction, and patients in whom the surgical area cannot be fully covered with soft tissue. After an amputation, prostheses will be needed.
- Lymphadenectomy: This is a surgical procedure in which lymph nodes are removed and a sample of tissue is checked under a microscope for signs of cancer. This procedure is also called a lymph node dissection.
- Gastrointestinal Stromal Tumours (GISTs) Surgery Treatment
The tumour and some surrounding tissue may be removed if the GIST has not spread and is in an area where surgery can be performed without risk. A laparoscope, a thin, illuminated tube, is occasionally used during surgery to view within the body. A laparoscope is put into one of the small incisions that are created in the abdominal wall. To remove organs or tissues, instruments might be placed through the same incision or through different incisions.
- Liposarcoma Surgery Treatment
The main form of treatment for liposarcoma is surgery. If the cancer is minor and hasn’t progressed to other regions of the body, it can be the only treatment a patient needs. The goal of surgery is to remove as much of the tumour as possible without damaging your arm or leg, which is where liposarcoma often starts.
Treatment for liposarcoma most frequently involves “limb-sparing” surgery. Only the tumour and a ring of healthy tissue surrounding it are removed by the surgeon. Getting excess cells eliminated ensures that the cancer won’t return.
- Uterine Sarcomas (including Endometrial Stromal Sarcoma and leiomyosarcoma) Surgery Treatment
Common surgical procedures for uterine cancer include:
- Hysterectomy:Depending on the extent of the cancer, the surgeon will perform either a simple hysterectomy (removal of the uterus and cervix) or a radical hysterectomy (removal of the uterus, cervix, the upper part of the vagina, and nearby tissues). For patients who have been through menopause, the surgeon will typically also perform a bilateral salpingo-oophorectomy, which is the removal of both fallopian tubes and ovaries.
A hysterectomy may be performed either by abdominal incision, by laparoscopy or robotically, which uses several small incisions, or vaginally. A hysterectomy is usually performed by a gynecologic surgeon, which is a surgeon who specializes in surgery of the female reproductive system. In robotic-assisted surgery, a camera and instruments are inserted through small, keyhole-sized incisions. The surgeon directs the robotic instruments to remove the uterus, cervix, and surrounding tissue. If the patient has no cancer remaining in the tissue removed during a hysterectomy, additional treatment may not be needed. However, regular screening and testing to check for a return of the cancer is recommended.
- Lymph node removal: At the same time as a hysterectomy, the surgeon may remove lymph nodes near the tumour to determine if the cancer has spread beyond the uterus.This may be done through a procedure called a sentinel lymph node biopsy or lymphadenectomy. A sentinel lymph node biopsy might involve an injection of dye into the uterus during the hysterectomy and removal of the few lymph nodes where dye collects. This procedure has become more common in uterine cancer than lymphadenectomy. A lymphadenectomy, or lymph node dissection, is a surgical procedure in which a group of lymph nodes is removed.
- Undifferentiated pleomorphic sarcoma (UPS) Surgery Treatment
Before surgery, chemotherapy may be given to make the tumour smaller. Chemotherapy is usually given so less bone tissue is removed and lowers the risks of problems after surgery.
The following types of surgery that may be done for Undifferentiated Pleomorphic Sarcoma (UPS):
- Wide local excision: This is a surgery to remove the cancer and some healthy tissue around it.
- Limb-sparing surgery: If the tumour is in an arm or leg, techniques to keep the arm or leg intact are used whenever possible. This is sometimes called “limb salvage” or “limb sparing.” However, amputation, which is the removal of the arm or leg with the tumour, is sometimes necessary. This depends on the tumour’s size and/or location.
- Amputation: For some patients, amputation may offer the best option for treating the sarcoma. These include people whose sarcoma is located where it cannot be completely removed by surgery, patients who cannot undergo reconstruction, and patients in whom the surgical area cannot be fully covered with soft tissue. After an amputation, prostheses will be needed.
- Rotationplasty: This is a Surgery to remove the tumour and the knee joint. The part of the leg that remains below the knee is then attached to the part of the leg that remains above the knee, with the foot facing backward and the ankle acting as a knee. A prosthesis may then be attached to the foot.
- Angiosarcoma Surgery Treatment
Angiosarcoma is a fast-growing cancer, so your doctors will treat it aggressively.
In surgery, Doctors will remove as much of the angiosarcoma as possible with surgery but sometimes it is not possible due to the location.
- Synovial Sarcoma Surgery Treatment
The main treatment for synovial sarcoma is surgery. The objective is to get rid of the malignancy together with a margin of healthy tissue. This may occasionally include amputating a leg or perhaps removing an entire muscle or set of muscles.
The doctor may advise a regimen of radiation therapy or chemotherapy in addition to surgery to lessen the likelihood of recurrence.
Radiation therapy is most commonly used for bone sarcoma tumours that cannot be removed surgically. Radiation therapy can be used before or after surgery to shrink the tumour or to destroy any remaining cancer cells. Radiation therapy allows for less invasive surgery, often preserving the arm or leg. Radiation therapy uses high-energy x-rays or other particles to destroy cancer cells. It may also be given as a palliative treatment to improve the patient’s quality of life by treating symptoms and side effects.
The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. Stereotactic body radiotherapy (SBRT) is a type of radiation therapy that may be used to treat bone sarcomas that have spread to the lungs. SBRT employs a small number of intensely focused radiation treatments to control or destroy a small area of tumour.
A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.
Bone Sarcomas
- Osteosarcoma Radiation Therapy
Osteosarcoma cells are not easily killed by external radiation therapy. It may be used when a small amount of cancer is left after surgery or used together with other treatments. This is done through:
- External-beam radiation therapy: External radiation therapyuses a machine outside the body to send radiation toward the area of the body with cancer.
- Brachytherapy: Also known as internal radiation therapyuses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.
- Ewing Sarcoma Radiation Therapy
For Ewing sarcoma, radiation therapy is used when surgery is not possible or if surgery did not remove all of the tumour cells, as well as when chemotherapy was not effective.
The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.
- Chondrosarcoma Radiation Therapy
Radiation therapy is a treatment option for some CS tumours that cannot be removed by surgery. When possible, patients may be considered for particle-based therapies (proton or carbon ion). Advanced image guidance and intensity-modulated radiotherapy may be used to deliver photon-based therapies.
- Giant Cell Tumours Radiation Therapy
For Giant Cell Tumours, radiation therapy may be done before surgery to shrink the tumor, or it may be done after surgery to destroy any remaining cancer cells. Radiation therapy makes it possible to do less extensive surgery, often preserving the arm or leg.
Soft Tissue Sarcoma Subtypes
Radiation therapy may be done before surgery to shrink the tumor so that it may be more easily removed. Or it may be done after surgery to remove any cancer cells left behind. Radiation treatment may make it possible to do less surgery, often preserving critical structures in the arm or leg if the sarcoma is located in one of those places.
- External-beam radiation therapy: External radiation therapyuses a machine outside the body to send radiation toward the area of the body with cancer.
- Brachytherapy: Also known as internal radiation therapyuses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.
- Proton beam radiation therapy: Proton therapy is a type of external-beam radiation treatment that uses protons rather than x-rays. Like x-rays, protons can destroy cancer cells. It is most commonly used in parts of the body close to critical structures, for example, near the spinal cord or at the base of the brain.
- Intraoperative radiation therapy: Part of the planned radiation therapy can be given during surgery. This approach can decrease the need to expose normal tissue to radiation from external-beam radiation or brachytherapy.
- Gastrointestinal Stromal Tumours (GISTs) Radiation Therapy
Radiation therapy is rarely used to treat GIST patients. It may, however, be used as a palliative treatment for pain relief, such as bone pain, or to stop bleeding.
- Liposarcoma Radiation Therapy
Radiation therapy may be used before surgery in liposarcoma to shrink the tumour so that it can be removed more easily. It could also be done after surgery to remove any cancer cells that were left behind. Radiation therapy may allow for less surgery, often preserving important structures in the arm or leg if the sarcoma is located in either of those areas.
- Uterine Sarcomas (including Endometrial Stromal Sarcoma and leiomyosarcoma) Radiation Therapy
Some patients with uterine cancer need surgery and radiation therapy. The radiation therapy is most often given after surgery to destroy any remaining cancer cells. Radiation therapy is occasionally given before surgery to shrink the tumour. If a patient cannot have surgery, the doctor may recommend radiation therapy instead.
Options for giving radiation therapy to treat uterine cancer may include radiation therapy directed towards the whole pelvis and/or applied only to the vaginal cavity, often called vaginal brachytherapy. A number of factors play into decisions about what type of radiation is best, but some patients with low-risk disease may be able to undergo vaginal brachytherapy instead of radiation to the pelvis.
Radiation therapy to the pelvis may also be considered for some patients with cancer that has spread through half or more of the thickness of the myometrium, depending on factors such as age and whether the cancer has spread to blood or lymphatic vessels.
- Undifferentiated pleomorphic sarcoma (UPS) Radiation Therapy
UPS cells are not easily killed by external radiation therapy. It may be used when a small amount of cancer is left after surgery or used together with other treatments. This is done through:
- External-beam radiation therapy: External radiation therapyuses a machine outside the body to send radiation toward the area of the body with cancer.
- Brachytherapy: Also known as internal radiation therapyuses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.
- Angiosarcoma Radiation Therapy
Radiation therapy can be used around the time of surgery. The radiation is aimed at the tumour area to prevent it from growing back after it is removed. Radiation therapy may also be used if the angiosarcoma cannot be removed with surgery.
- Synovial Sarcoma Radiation Therapy
Treatment for synovial sarcoma depends on whether it has spread. Given that synovial sarcoma can grow for a while before it is found, there is a greater chance that it will spread to other parts of the body. Sometimes radiation therapy is used before or after surgery to kill cancer cells.
Chemotherapy is the use of drugs to destroy cancer cells, typically by preventing cancer cells from growing, dividing, and continuing to spread.
A chemotherapy regimen, or schedule, typically consists of a predetermined number of cycles administered over a set period of time. A patient may be given one drug at a time or a combination of drugs at the same time. Chemotherapy for bone sarcoma is typically administered as an outpatient treatment, meaning it is administered at a clinic or doctor’s office rather than in a hospital.
Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). However, chemotherapy for Ewing sarcoma is usually injected into a vein or muscle; it is rarely given by mouth.
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive one (1) drug at a time or combinations of different drugs given at the same time.
Chemotherapy is often used when a sarcoma has already spread. It may be given alone or in combination with surgery, radiation therapy, or both.
Targeted therapy is a type of cancer treatment that targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
The targets of all tumours are not the same. The doctor may order tests to identify the genes, proteins, and other factors in a patient’s tumour to find the most effective treatment. This enables doctors to provide the most effective treatment to each patient whenever possible.
Targeted therapy for battling both bone sarcomas and soft-tissue sarcomas subtypes may include:
- Monoclonal antibody therapy: Monoclonal antibodies are immune system proteins made in the laboratory to treat many diseases, including cancer. As part of a cancer treatment, these antibodies can attach to a specific target on cancer cells or other cells that may help cancer cells grow. The antibodies can then kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Ganitumab is a monoclonal antibody being studied to treat metastatic Ewing sarcoma.
- Kinase inhibitors:Blood vessels make up a large part of Kaposi sarcoma lesions, so there are many studies on treatments focused on stopping angiogenesis, which is the process of making new blood vessels. The goal of anti-angiogenesis therapy using kinase inhibitors is to block the formation of new blood vessels so that the nutrients a tumour needs to grow and spread cannot be delivered. This causes the tumour to “starve.”
- NEDD8-activating enzyme (NAE) inhibitor therapy:NAE inhibitors are drugs that attach to NAE and stop the cancer cells from dividing. Pevonedistat is an NAE inhibitor being studied to treat recurrent Ewing sarcoma.
- Immunomodulatory drugs: Immunomodulatory (or immune modulating) drugs are medications that change the way the body’s immune system works and interacts with tumour cells, and they may also block the formation of new blood vessels in the tumour.
- Mammalian target of rapamycin (mTOR) inhibitors: This treatment blocks a protein called mTOR, which may keep cancer cells from growing and prevent the growth of new blood vessels that tumours need to grow. Everolimusis an mTOR inhibitor used to treat recurrent osteosarcoma.
- Sirolimus protein-bound particles (Fyarro): Sirolimus is a kinase inhibitor that targets the mammalian target of rapamycin (mTOR). This medication may be given as an infusion to treat perivascular epithelioid cell tumour (PEComa) that is locally advanced and cannot be removed with surgery, as well as metastatic malignant PEComa. PEComa is a type of rare tumour that forms in the soft tissues of the stomach, intestines, lungs, female reproductive organs, and genitourinary organs. Most PEComas are benign.
Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This cancer treatment is a type of biologic therapy.
- Immune checkpoint inhibitor therapy:This treatment blocks certain proteins made by some immune system cells, such as T cells. These proteins help keep immune responses in check and can keep T cells from killing cancer cells. When these proteins are blocked, the inhibitors on the immune system are released and T cells can kill cancer cells. Nivolumab and ipilimumab are types of immune checkpoint inhibitors being studied to treat recurrent Ewing sarcoma.
- CAR T-cell therapy:This treatment changes the patient’s T cells (a type of immune system cell) so they will attack certain proteins on the surface of cancer cells. T cells are taken from the patient and special receptors are added to their surface in the laboratory. The changed cells are called chimeric antigen receptor (CAR) T cells. The CAR T cells are grown in the laboratory and given to the patient by infusion. The CAR T cells multiply in the patient’s blood and attack cancer cells. CAR T-cell therapy is being studied to treat recurrent Ewing sarcoma.
Immunotherapy is generally not approved for the treatment of soft tissue sarcomas because they have not yet shown significant benefit. Many immunotherapy treatments for other types of cancers involve “immune checkpoint inhibitors.” These drugs are given to take the brakes off the body’s natural immune response against the cancer in the body. The current immunotherapy treatments can cause problems because these drugs also activate immune responses against normal body parts, leading to side effects from an overactive immune system.
Are there any Side Effects of Sarcoma Treatment?
Surgery is often a long and complex operation. Serious short-term side effects are not common, but they can include reactions to anesthesia, excess bleeding, blood clots, and infections. Pain is common after the operation, and strong pain medicines might be needed for a while after surgery as the site heals.
The long-term side effects of surgery depend mainly on where the tumour is and what type of operation is done.
Complications of limb-sparing surgery can include possible breaking or loosening of bone grafts or prostheses. This is more likely than with bone surgery done for other reasons because the chemotherapy used before and after surgery can increase the risk of infection and affect wound healing. Infections in the area can be very serious because they can be hard to treat and might require further surgery. Infections are also a concern in patients who have had amputations, especially at part of a leg, because the pressure placed on the skin at the site of the amputation can cause the skin to break down over time.
In surgery, the common side effects may be:
- Bleeding
- Blistering
- Infection
- Tissue or vessel damage
- Nerve damage
- Pain
- Fatigue
- Loss of appetite
- Scarring
- Sexual dysfunction
- Ulcers
- Wound opening
The possible side effects of radiation therapy depend on where the radiation is targeted. The common side effects include:
- Skin irritation (in areas of radiation, ranging from redness, blisters, and peeling)
- Hair loss
- Fatigue
- Nausea
- Diarrhoea
- Lower blood cell counts
- Increase risks of infections
- Mouth and gum sores/difficulty swallowing/dry mouth
- A type of swelling called lymphedema
The side effects of chemotherapy commonly include the following:
- Nausea and vomiting
- Diarrhea
- Constipation
- Tiredness
- Pain
- Loss of appetite
- Hair loss
- Skin and nail changes
- Numbness and tingling
- Swelling
- Low white blood counts, low red blood counts and low platelet counts
- Risks of infections
- Risk of infertility
Depending on the targeted drugs used, the common side effects may include:
- Low or High blood pressure
- Increased blood sugar level or cholesterol
- Fatigue
- Nausea and vomiting
- Diarrhoea
- Poor appetite and weight loss
- Voice changes
- Vision problems
- Skin rash/Mouth sores
- Swelling in the arms and legs (fluid build-up)
- Constipation
The side effects of immunotherapy may include:
- Nausea and vomiting
- Diarrhea
- Constipation
- Swelling of hands and feet
- Rash and other skin changes
- Vision problems
- Problems with the gastrointestinal tract
- Lowered blood counts
- Risk of infertility
- Bone marrow suppression
What do I need to do if I have Sarcoma?
Not all sarcomas are the same. Each has a different natural history – from where they start, how they affect the body, how fast they grow, and how they respond to treatment.
If you suspect that you or your loved one have sarcoma, it is advisable to get the support you need. Early detection and diagnosis of sarcoma is key to treating the disease.
Regardless of what stage your Sarcoma may be at, you should schedule an appointment to see an oncologist specialising in Sarcoma as soon as possible. With the speed of developments in sarcoma diagnosis and treatment, novel emerging treatment options could be explored by your medical oncologist.
Our cancer specialists at OncoCare specialise in treating late stage and advanced stages of sarcoma, as well as earlier stages of the disease.
Who are the Sarcoma Specialists in Singapore?
Senior Medical Oncologist
MBBS (S’pore), Grad Dip (GRM), MRCP (UK), M Med (Internal Med)
Dr Angela Pang is a Senior Medical Oncologist at OncoCare Cancer Centre and also a visiting consultant at the National University Cancer Institute of Singapore (NCIS).
Prior to this, she was a Consultant with the Haematology-Oncology Department of National University Cancer Institute of Singapore (NCIS), National University Hospital (NUH) and Visiting Consultant at Ng Teng Fong General Hospital (NTFGH).
She had obtained her undergraduate degree from the School of Medicine, National University of Singapore (NUS). Thereafter, she obtained her postgraduate qualifications – Masters in Medicine (Internal Medicine) from NUS, and her Membership of the Royal College of Physicians (UK). Subsequently, she went on to complete her advanced specialist training in Medical Oncology in the National University Hospital (NUH), Singapore and was awarded the NCIS research scholarship for her Sarcoma research fellowship with Professor Robert G Maki in the Tisch Cancer Institute, Mount Sinai Hospital, New York.
With a specific interest in the optimisation of care in elderly cancer patients, Dr Pang further pursued a Graduate Diploma in Geriatric Medicine with the Yong Loo Lin School of Medicine (YLLSOM). In order to integrate her expertise in both geriatrics and oncology, she also trained in Geriatric Oncology with Dr Beatriz Korc and Dr Stuart Lichtman in the Memorial Sloan Kettering Cancer Center, New York.
Dr Pang’s main clinical interests are in bone/soft tissue sarcomas, gastrointestinal cancers and geriatric oncology. She was the co-lead for the Musculoskeletal oncology service in NCIS, and had set up of the multi-disciplinary Geriatric Oncology service in NCIS and NTFGH.
She was also a principal investigator for several international multi-centre cancer clinical trials and also a recipient of several grants. Her research work has been published in peer reviewed journals including the Journal of Clinical Oncology (JCO), Journal of American Society of Medicine (JAMA) Oncology, Nature Communications, Clinical Cancer Research, British Medical Journal (BMJ) GUT, Oncogene, Oncotarget and others.
She is a member of several professional bodies, including the American Society of Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), International Society of Geriatric Oncology (SIOG) and the Connective Tissue Oncology Society (CTOS).
Dr Pang was also actively involved in both undergraduate and post graduate educations at the YLLSOM and NUH respectively. She has been awarded for teaching excellence and was previously appointed as Assistant Professor for Faculty of Medicine, YLLSOM and had served as core faculty of the undergraduate education (Medical Oncology) and Senior Residency (Medical Oncology) of NUH.
Dr Pang is fluent in English, Mandarin and Hokkien. She is able to converse in simple Malay/Bahasa. She has taken care of patients from many regional and overseas regions including Malaysia, Indonesia, Vietnam, Myanmar, China, Bangladesh, Sri Lanka, India, Canada and Mongolia.
- Graduated from the National University of Singapore with MBBS in 2005.
- Obtained Membership of the Royal College of Physician (United Kingdom) and Masters in Internal Medicine (NUS) in 2009.
- Awarded the NCIS scholarship (2015-2016) as a Sarcoma research scholar at The Tisch Cancer Institute, Mount Sinai Hospital with Professor Robert Maki.
- Attended the Geriatric Oncology Program at the Memorial Sloane Kettering Cancer Centre (New York) in 2016.
- Co-lead for the Musculoskeletal Oncology (Sarcomas) service in NCIS
- Built and served as the Program director of the Geriatric Oncology service in NCIS and NTFGH.
- Assistant Professor Yong Loo Lin School of Medicine, National University of Singapore from 2017 – 2022.
- Authored or co-authored publications in peer-reviewed international journals including Journal of Clinical Oncology (JCO), Journal of American Society of Medicine (JAMA) Oncology, Nature Communications, Clinical Cancer Research, British Medical Journal (BMJ) GUT, Oncogene, Oncotarget and others.
- Recipient of multiple teaching awards:
- NUHS Interprofessional teaching award in 2014.
- NCIS Department Postgraduate teaching excellence award in 2015
- NUHS Educator’s Day Collaboration Award in 2021.
- Recipient of the Singapore Patient Engagement Initiative Award for the NCIS Dream Makers’ Program in 2021.
- Recipient of several grants including Singapore Cancer Society Grant, Jurong Health Fund grant, NUHS bridging grant and the National Medical Research Council (NMRC) Clinician Investigator Salary Support Programme.
- Member of several professional bodies including American Society of Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), International Society of Geriatric Oncology (SIOG) and the Connective Tissue Oncology Society (CTOS).
- Sub-specialty oncology interest in bone/soft tissue sarcomas, gastrointestinal cancers and geriatric oncology.
Senior Consultant, Medical Oncologist
MBBS (Singapore) – ABIM Int. Med (USA) – ABIM Med Onc(USA) – FAMS (Medical Oncology)
Dr. Tay has been recognised as one of the top cancer doctors doing research. He was awarded the prestigious center grant by the National Medical Research Council of Singapore. He actively collaborates with other leading Asian researchers based in Korea, Taiwan, Hong Kong and USA. Dr Tay has published his findings in numerous journals, including Nature Genetics, the Journal of Clinical Oncology, The Lancet Hematology, American Journal of Medicine, Leukemia & Lymphoma and Seminars in Hematology.
Dr Tay’s subspecialty interest is in women related cancers such as breast cancers & gynaecological cancers, melanoma, brain cancers, soft tissue & bone sarcomas and also hematological malignancies such as lymphoma, multiple myeloma and leukemia.
- Graduated from the National University of Singapore in 1998.
- Board Certified, Internal Medicine, American Board of Internal Medicine, 2006
- Board Certified, Medical Oncology, American Board of Internal Medicine, 2009
- Chief Resident, Department of Medicine, John A. Burns School of Medicine, University of Hawaii, 2006
- Chief Fellow, Medical Oncology Branch, National Cancer Institute, National Institute of Health, Bethesda, 2008
What is Sarcoma?
Definition of Sarcoma
Sarcomas are cancers that develop from bones or soft tissues, such as fat, muscles, nerves, and more. Because bone and soft tissues can be found nearly everywhere in the body, sarcoma can start in any part of the body.
- 60% begin in an arm or leg
- 30% start in the torso or abdomen
- 10% occur in the head or neck
Not all sarcomas are the same. Because there are more than 50 different types of sarcomas and each has a different natural history – meaning where they start, how they affect the body, how fast they grow, and how they respond to treatment – it is more accurate to describe them as a family of related diseases rather than as a single disease.
Specific types of sarcomas are often named according to the normal tissue cells they most closely resemble. This is different from most other types of cancer, which usually are named for the part of the body where the cancer began. Some sarcomas do not look like any type of normal tissue and are thought to come from stem cells or other primitive cells. Stem cells are special cells that can mature into specific tissues or organs.
Sarcomas accounts for about 1% of all adult cancers in Singapore. As sarcoma is rare, globally each year, approximately 4 out of 100,000 are diagnosed with sarcoma, with men more likely than women to develop bone or soft tissue sarcoma.
What are the Signs and Symptoms of Sarcoma?
The most common symptoms of Sarcoma are:
- Abdominal pain
- Weight loss
- Bone swelling and pain which tends to worsen at night
- Develop fractures or broken bones after minor injury or trauma
A new lump that may not be painful located anywhere in the body that increases in size, and may grow to a large size over time (in patients experiencing soft tissue sarcomas)
Screening for Sarcoma
There are no screening tests or exams recommended for patients with no history of sarcoma or other sarcoma risk factors. The best approach to early detection is to inform the doctors of any unexplained lumps, growths or pain that may be caused by sarcoma.
How Sarcoma is Diagnosed
Since there are no standard screening tests for sarcoma, the doctor will usually examine any unusual or new lumps or bumps that are growing to make sure it is not cancer. A diagnosis of sarcoma is made by a combination of clinical examination by the doctor and imaging tests. It is confirmed by the results of a biopsy.
Tests to diagnose Sarcoma include:
- X-ray: An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. X-rays are particularly useful for bone sarcomas.
- Ultrasound: An ultrasound uses sound waves to create a picture and may be used to look at lumps under the skin or other organs in the body.
- CT (or CAT) Scan: Thisis a series of detailed pictures of areas inside of the body. A CT scan can be used to measure the tumour’s size or see if the cancer has spread somewhere else.
- Magnetic Resonance Imaging (MRI): This exam uses a powerful magnet linked to a computer to create detailed pictures of the body. MRI scans use radio waves and strong magnets instead of x-rays.
- PET Scan: This examuses sugar that is modified in a specific way, so it is absorbed by cancer cells and appears as dark areas on the scan.
- Biopsy: Thisis the removal of tissue. A pathologist studies the tissue under a microscope to make a diagnosis. A biopsy is the only sure way to tell whether a person has cancer.
- Tissue testing of the tumour: The doctor or the pathologist looking at the sarcoma may recommend running laboratory tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumour. Results of these tests will help decide what the treatment should be, because each sarcoma can be as different from one another.
What are the Causes and Risk Factors of Sarcoma?
Most sarcomas do not have known causes. The following factors may raise a patient’s risk of developing sarcoma:
- Previous radiation therapy: Patients who were treated with radiation therapy for a previous cancer, usually more than five years ago, have a slightly increased risk of later developing sarcoma in the area where the radiation was directed.
- Genetics: Patients with certain inherited diseases have a higher risk of sarcoma. These diseases include neurofibromatosis type 1, also known as von Recklinghausen’s disease; familial adenomatous polyposis, also known as Gardner syndrome; Werner syndrome; tuberous sclerosis complex; nevoid basal cell carcinoma syndrome; Li-Fraumeni syndrome; and retinoblastoma.
- Immune system abnormalities: Patients with issues with their immune system have a higher risk of several types of cancer, whether from infections such as human immunodeficiency virus (HIV), cancers such as chronic lymphocytic leukemia, or autoimmune conditions such as lupus or psoriasis.
- Lymphedema: Patients who have surgery or radiation therapy for other reasons may have swelling of an arm, leg, or other part of the body as a side effect of the treatment. This is called lymphedema. Sarcomas may occasionally form in areas where lymphedema had developed.
- Benign tumours or other bone conditions: Paget’s disease of the bone may lead to osteosarcoma. Other noncancerous bone diseases, such as fibrous dysplasia, may increase the risk of osteosarcoma.
What are the Types of Sarcomas?
There are two main types of sarcomas. The most common is soft tissue sarcoma, which develops in the soft tissues of the body, usually the muscles or blood vessels. The other type of sarcoma is less common and is known as bone sarcoma as it forms in the bone.
Within the two main types of sarcomas, there are more than 70 different subtypes. They are classified based on where in the soft tissue or bone the cancer originated. Some of the most common subtypes of sarcoma include:
- Osteosarcoma – Develops in cells that form bones
- Dermatofibrosarcoma protuberans (DFSP) – Develops in the skin
- Fibrosarcoma (fibroblastic sarcoma) – Develops in fibrous tissue
- Chondrosarcoma – Develops in cartilage
- Ewing’s sarcoma – Develops in bone cells or immature soft tissue
- Undifferentiated pleomorphic sarcoma (UPS) – UPS is an uncommon bone tumour, most closely related to osteosarcoma. UPS of bone is usually found in adults. An arm or leg, especially around the knee joint, is the most common place for UPS to appear.
- Rhabdomyosarcoma – Develops in cells that form skeletal muscles
- Liposarcoma – Develops in fatty tissue
- Synovial sarcoma – Develops in the cells near the tendons and joints
- Gastrointestinal stromal tumor – Develops in the cells that line the gastrointestinal tract
- Kaposi’s sarcoma – Develops in the cells that line lymph or blood vessels
- Leiomyosarcoma – Develops in the muscles of organs in the pelvis and abdomen
- Angiosarcoma – Develops in the inner lining of the blood vessels
What are the Stages of Sarcoma?
Staging is a way of describing where the cancer is located, or if it has spread and whether it is affecting other parts of the body. The tests and scans used to diagnose the patient’s cancer will give some information about:
- the type of cell the cancer started in and where it began
- how abnormal the cells look under the microscope (the grade)
- the size of the cancer and whether it has spread (the stage)
Doctors also describe sarcomas by its Grade. The grade describes how much cancer cells look like healthy cells when viewed under a microscope.
The doctor compares cancerous tissue with healthy tissue. Healthy tissue usually contains many different types of cells grouped together. If the cancer looks like healthy tissue and has different cell groupings, it is called “differentiated” or a “low-grade tumour.” If the cancerous tissue looks very different from healthy tissue, it is called “poorly differentiated” or a “high-grade tumour.” The cancer’s grade may help the doctor predict how quickly the cancer will spread.
There are four (4) grades for sarcoma: GX (the grade cannot be evaluated), G1, G2, and G3. In general, the lower the tumour’s grade, the better the prognosis. The grades are determined based on the factors below:
- Differentiation: How different cancer cells are from normal tissue cells.
- Mitotic count: How many tumour cells are dividing.
- Tumour necrosis: How many tumour has cells that are dying.
Doctors also use the following terms to describe the stage to decide on the treatment plan:
- Localised: The tumour is only in the bone where it began and in the tissue around it. The tumour has not detectably spread to other parts of the body.
- Metastatic: The tumour has spread from the bone where it began to another part of the body. Most often, it has spread to the lungs or other bones.
- Recurrent: Recurrent Osteosarcoma & UPS is a tumour that has come back during or after treatment. It can come back in the same place where it started or in another part of the body. Osteosarcoma recurs most often in the lungs and rarely other bones. If there is a recurrence, the cancer may need to be staged again. This is called re-staging.
Stage l: The tumour is small and low grade.
- Stage IA:The tumour is low grade or cannot be graded and 8cm or smaller. It has not spread to any lymph nodes or to other parts of the body.
- Stage IB:The tumour is low grade or cannot be graded and larger than 8cm or there are more than 1 separate tumours in the primary bone site. It has not spread to any lymph nodes or to other parts of the body.
Stage ll: The tumour is small and higher grade.
- Stage IIA:The tumour is high grade and 8cm or smaller. It has not spread to any lymph nodes or to other parts of the body.
- Stage IIB:The tumour is high grade and larger than 8cm. It has not spread to any lymph nodes or to other parts of the body.
Stage III:There are multiple high-grade tumours in the primary bone site, but they have not spread to any lymph nodes or to other parts of the body.
Stage lV: The cancer has spread to other parts of the body. The original tumour can be any size, any grade, and may or may not have spread to the regional lymph nodes.
- Stage IVA:The tumour is of any size or grade and has spread to the lung(s).
- Stage IVB:The tumour is of any size or grade and has spread to the lymph nodes or the tumour is of any size or grade and has spread to another bone or organ besides the lung.
One tool that doctors use to describe the stage is the TNM system. Results from diagnostic tests and scans are used to answer these questions:
- Tumour (T): How large is the primary tumour? Where is it located?
- Node (N): Has the tumour spread into the lymph nodes? If yes, where and how many?
- Metastasis (M): Has the cancer spread to other parts of the body? If yes, where, and how much?
The results are combined to determine the stage of cancer of each patient and to plan the best treatment.
