1. Oncology Update Louis Lao

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

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

4. 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

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

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

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

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

9. Targeted Therapy

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

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

12. 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

13. 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

14. SABR/SBRT

15. 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

16. Conventional RTSABR Courtesy of Elekta Inc.

17. Local control ~90% Nagata et al IJROBP 2011

18. Pre SABR 3 mths post SABR 6 mths post SABR

19. Pre SABR1 mth post SABR