She is also widely known as the “Spirit of the Century”, an award conferred upon her by the Singapore public in a national contest held to identify the role model for the 21st century. Dr Lim is in active general surgery practice at the two premier hospitals in Singapore (Mount Elizabeth and Gleneagles Hospitals) with practices in breast surgery, abdominal and gastrointestinal surgery, liver, gallbladder and pancreatic surgery, advanced laparoscopic surgery, transplantation, colon and rectal diseases and cancer, and robotic surgery.
Dr Susan Lim was recently conferred upon the position of Fellow of Trinity College, University of Melbourne, Australia, making her the youngest ever to be elected Fellow of the College. This is the highest honour the college can bestow and is awarded only to individuals of truly outstanding achievement. Excerpts from the interview.
Middle East Medical magazine: Any reason for you to choose Singapore as your base?
Dr Susan Lim: We have principal investigators from Europe – such as Spain – the UK and now from Australia all anchoring at Singapore. The reason why we chose Singapore is that the country’s legislation is very receptive to stem cell research. And also the government has put in place a strong infrastructure. We are just trying to leap frog on that.
Now one of our principal investigators from Spain - Professor Bernat Soria - is currently the chairman of the European stem cell network and also the principal investigator of the diabetic arm of the project at SCT.
He has been responsible for some landmark research in animal models where they have been able to create insulin-secreting cells from fat. So what we are doing here is that we are putting in genetic material into the fat cells and stimulating these stem cells to become insulin-producing islet cells and then inject these islet cells into the system.
The benefit from this type of therapy is that, insulin therapy as we know of, is not very optimal, in that if we don’t inject it there is a failure of the glucose balance in the body. But with the insulin producing islets, since they are present inside the body of the individual, it would respond to the glucose homeostasis and with any luck in research we may be able to go for a year or two with just one booster of the genetically-engineered injection.
MEM: What has been the focus area of your team?
SL: I would like to focus on the type of stem cell that can be easily used in the patient - and that is adult stem cells. They are non controversial because they come from the individual itself. Which means that the person could act both as the source of the cells and the recipient of the differentiated tissue.
Generally the source could include tissue extracted from the bone marrow, skin cells, and fat cells, among others. But I have decided to use the tissue that most people would be more eager to part off with - adult fat cells. It is like a petroleum reserve if I may say. Everybody has their own reserve of these fat cells, which means that time-to-time, whenever we may need it, we can harvest these cells in abundance. The applications are manifold. It can be used to offset a Wayne Rooney type of injury, whereby the cartilaginous cells can be repaired. This apart it has several benefits that can spin off into the horseracing area as well, where the horses can be treated for sports injuries. We already know that we can differentiate these fat cells into heart muscle cells (cardiomyocytes), so that patients suffering from heart failure can benefit from these cells, which is short of a transplant. The new cells can boost up the performance of the heart and offer more vigour.

MEM: So the field does hold a lot of promise …
Yes it does hold a lot of promise for the treatment of several diseases both in men and women. One of the applications in women is to help offset the problems of incontinence. After a certain age the muscle sphincter in women gets weaker and could give rise to urinary incontinence. Recently through research we are trying to strengthen the muscle so that we can try and put in a very minimally invasive treatment for women with urinary incontinence.
As we move, there are other applications for the new therapy, especially to tackle disorders such as the one sustained by former Superman (Christopher Reeve). He has invested a lot of money into the discovery of treatment for such severe nerve damage through the use of embryonic stem cells. A lot of work has been initiated in this direction and over the years and we are now trying to build on what we have known from embryonic stem cell research and its application in adults. What we are now trying to do is generate nerve fibres, from stem cells and the results from such a study could be applicable in spinal cord injuries. Further development on the same lines could also lead to the treatment of diseases such as Parkinsons and Alzheimer’s. Stem cell research also holds a lot of promise for the treatment of diabetes.

MEM: What could be the more immediate applications?
But before we reach all these, we have found a more immediate application in the cosmetic industry, which apart from being lucrative can help further research in stem cells.
What we have been doing is generating stem cells from fat, which involves finding the baby fat cells that will eventually perform as natural fillers. These baby fat cells can then be used by plastic surgeons to inject into the face or such other areas in the body that require an enhancement.
So we would have developed a natural substitute for Botox or such other fillers. We expect such augmentations to last longer. This development could be an immediate commercial spin off to the stem cell technology, which would then attract the industry as well as the venture capitalists. Because research is a long haul and if we there is something that is tangible and offer immediate rewards for investment, then the support could be much stronger. This could help us provide care in other areas such as cartilage replacement, cardiac muscle replacement and in the longer run, even diabetes.

MEM: Could you elaborate on the work done in the field of diabetes?
Right now every one is thinking of injecting the islet cells to the liver, because of its proximity to the pancreas and it also enjoys all the nourishment from the gut. But we are also exploring other areas, and one of the areas that I personally feel is better is to place it in the cells of the rectum, very much like a haemorrhoid injection. The reason for that is that it is very easy to do. The procedure can be done as an outpatient and the patient can be walking out of the hospital in a couple of hours. In addition, there are other benefits such as: you can examine it such as in a normal haemorrhoid exam, you can biopsy it, you can easily boost it up. So I feel that when we think about sites we will have to think about accessible sites. The reason that the site could be ideal is also for the fact that the gut, the liver and the rectum all drain into the portal circulation (entero-hepatic circulation) and it is the right place for insulin delivery, because Glucose is present here. And if that doesn’t work then we have to consider the placement into the liver using a catheter, which would be very much like a cardiac angiogram.

MEM: … so the site is not a problem?
No, the site is not going to be too much of a problem. The problem is with the ways and means of generating the cells. We are currently looking into the best sites - whether it is abdominal or visceral - from where we can possibly harness the best stem cells in the body.
We are also looking at best possible age groups - whether fat cells derived from 70-year-old are as active and vibrant as that of a 40-year-old, or which gene pool could offer us the best possible sample. The possibilities are endless. There is lots of research that needs to be done in the process, where several research/educational facilities can participate.

MEM: How close are we to a cure for diabetes?
The important thing to realise is that although it sounds a long way away, because you have to make the islets (beta cells) and then the beta cell has to be in an islet cluster, and this islet cluster has to respond to glucose. This is asking a lot from the research point of view. So we are looking forward to at least five years of research here, but cell therapy for diabetes is going to commence from next year, if not this year. For this we are going to look at the complications affecting diabetes, which include gangrenous legs, peripheral neuropathy, weak hearts, poor circulation, and we have to reach out to these ailments.
So what we are trying to do is to generate stem cells that will then be able to heal ischemic legs, and this is already being done. We already have a centre for cell therapy in Singapore and we hope to use that treatment for treating patients suffering from the complications of diabetes. Our idea is not just to develop cells that can produce insulin as a part of the diabetic programme, but also treatments that can be used in parallel to help minimize or negate the effects of diabetes on the patients, caused by the death of tissue.
So for example, there are cases whereby patients with ischaemic legs are being treated for tissue damage using cells that are harvested from their own bone marrow, or from their fat, and these legs heal very well. So what we now need to do is to conduct randomized trials to prove that the achievements that we have achieved in a few patients can be replicated in others as well. So this is what needs to be done now. Because diabetics across the world will not have to think that they may not be around when the eventual treatment of diabetes through the implantation of insulin secreting cells is achieved, since they can start off with the treatment of their complications, which can bring them back to their normal fully functional life, before the final cure is administered.

MEM: What plans do you have in mind for the Middle East?
We are planning to enter the Dubai market and the Abu Dhabi, the reason being that diabetes is a major problem for both Asia and the Middle East. These two regions have the fastest growth in type 2 diabetes worldwide. Dubai is a great place to start such a treatment primarily because it is very entrepreneurial.
SCT has focussed over the last few years on developing the basic building blocks and we have come out of the National University of Singapore and we have labs in Biopolis since it has all the cell processing facilities and the GMP facilities for us to then process the cells, package it and then keep ready for the clinic. So now we are in the pre clinical stage and feel that this is the time to look for partners and collaborators who will help kick start the project in the various countries. For the moment, the research labs will remain in Singapore, until such a time that there is a lab that can take the science, and we will be very happy to share the science in the Middle East. We are coming here for the third year now to lecture on stem cells and every year we have a different conversation, if anybody has been with it from the start. I am talking about the road that we have traversed from hypothesis to the preclinical stage. May be the next time we are here at the Arab Health we will be able to talk about some clinical trials as well as hope to announce a regional partnership as well.
We already have struck very strong partnerships with the Monasch University, of Australia, and Prof Bernard Soria in Spain and with Prof Mark who works out of the Barts & Queen Marys Hospital.

MEM: Any partnerships that you are planning to enter?
It is like an exchange of science without boundaries and may be we could host a talk on all the achievements we have had in the field of stem cell research in Dubai next year. It would be a good thing to do once we have found a strategic partner. It is not someone who will offer funds for funds sake, but someone who will con-invest and develop the project for the Middle East. And with con-investing they would able to share the research that is ongoing. It will be sort of a pilot project for the Middle East.
I think the area is developing quite a few science parks, such as the Dubiotech, DHCC, or one with some hospital with a surgery arm could be helpful. What we are looking for is not basic research, because that is done back in Singapore, but clinical or translational research, where the focus would be on introducing regenerative medicine and cell therapy. Such a service would be provided by the local facility in Dubai, apart from the regular healthcare service. I think it is not good enough to just take the cells from some company and place it in, but they have to understand the underlying science. And this would mean they should be able to tie down the concepts behind the science and employ them to the specific areas of medicine as well. This is not high-end research, since it is not using animal tissue, but using tissues from the individuals themselves.

MEM: How has it been for you to come to where are you are now?
When I completed the first liver transplantation in Singapore, I had to look out for cells from cadavers or from prisoners. But then, when stem cell research came about, I realised this must be the way to go.
Nowadays we are all moving on to the 80’s, 90’s, we have been trying to push the age factor further. Technological advancements could soon push medical science to the level, whereby body repair could be progressed with, very much the same way that is done in the automotive sector for instance, and we could try and extend life further by about another 50 years. It could be a very dramatic change for human living as such.
If we can screen away major killers such as heart disease, cancer and diabetes, we need to be bothered only about normal wear and tear, which we can get through with regenerative medicine. Stem cells is the new technology that will see us through into the next decade, just as drug research has been for the past couple of decades. Now all drug companies are eager to get a piece of the action. There has been a normal progression from drugs to monoclonal antibodies, to gene therapy (which really never took off) to stem cell research now.

MEM: Could you talk through some other applications of stem cells?
As a spin off to all the study we have made so far we have realised that stem cells can also be used effectively against cancer. There are quite a few cases whereby patients have been cured of various cancers only to realise later that there has been a relapse of disease a few years later.
Researchers in some parts of the world have now identified cancer stem cells in two solid organ tumours - prostate and breasts. Now, if we could develop a monoclonal antibody to switch off the protein on that tumour then that would be a great path breaker in the treatment of cancers.
MEM: What if stem cells themselves become cancerous?
This is the biggest criticism on embryonic stem cells. Although they are easier to handle, produce results so fast, there is a possibility showing cancerous properties, which is why we have not been working on such cells. 

MEM: How long do the stem cells derived from adipose tissue live?
Such stem cells do not show as many divisions as the ones shown by embryonic cells.
We have to really coax it to develop it into
an embryonic stem cell, which is why researchers were not interested in working with this type of tissue.