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 ablationIGTA

• 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 RT SABR

Courtesy of Elekta Inc.

Local control ~90%

Nagata et al IJROBP 2011

Pre SABR

3 mths post SABR

6 mths post SABR

Pre SABR 1 mth post SABR