Oncology Update Louis Lao

Objective How to cure cancer in the Asian population (20min)

Advances in NSCLC PET EBUS IGTA VATS Targeted Therapy SABR/SBRT

Multidisciplinary care is key! Respiratory medicine - EBUS Radiology/Nuclear Med – PET/IGTA Pathology – Molecular profiling Surgical Oncology - VATS Medical Oncology – Targeted therapy Radiation Oncology – SABR/SBRT

PET Functional/metabolic imaging FDG PET-CT Sensitivity ~90% Specificity ~80% Standard work up for pt undergoing curative intent Rx

EBUS Bronchoscopy using U/S to visualise and sample mediastinal LNs Allows accurate staging Reduces need for mediastinoscopy or thoracoscopy

Image guided thermal ablation IGTA Radiofrequency ablation (RFA) Microwave ablation (MWA) Thermal ablation Out patient Rx Risk of pneumothorax

Video assisted thoracoscopic surgery (VATS) Minimally invasive technique Instead of open thoracotomy Small incision Less Pain and quicker recovery c/f open surgery

Targeted Therapy

Driver Mutations EGFR ALK KRAS ROS1 MET BRAF PIK3CA HER2 FGFR1 Β-catenin RET DDR2 MEK1

Mutation rate in Asians EGFR mutation –West~15% –Asian~50-60% ALK translocation –West~4% –Asian~4%

Targeted Drugs/ Personalised medicine Drugs that target specific molecular pathways EGFR –TKI : Erlotinib (Tarceva), Gefitinib (Iressa), Afatinib ALK –Crizotinib, Ceritinib, Alectinib RAS/MEK –Selumetinib ROS1 –Crizotinib BRAF –Dabrafenib RET translocation –Vandetanib, Cabozantinib

TKI in EGFR mutated NSCLC Advanced NSCLC (Stage 4) High response rate (60~80%) RCTs show sig better progression free survival c/f chemo Toxicity –Generally well tolerated –Skin rash –Diarrhoea

SABR/SBRT

SABR Stereotactic Ablative Radiotherapy Delivery of ablative dose to a target Single/few fractions of very large doses per fraction Short treatment course Conformal planning Precise targeting using image guidance (IGRT) Non invasive

Conventional RTSABR Courtesy of Elekta Inc.

Local control ~90% Nagata et al IJROBP 2011

Pre SABR 3 mths post SABR 6 mths post SABR

Pre SABR1 mth post SABR