AGITG 2019 Annual Scientific Meeting Highlights of Interest to Radiation Oncologists

This year the AGITG Annual Scientific Meeting includes many sessions of interest to Radiation Oncologists, outlining the most up-to-date knowledge in Radiation Oncology with national and international Invited Faculty.

Invited Faculty members of interest to Radiation Oncologists include:

Associate Professor Manisha Palta – Duke University School of Medicine, USA

Dr Manisha Palta is a Radiation Oncologist and the Director of Clinical Research in the Department of Radiation Oncology at Duke University and is a member of the Duke Cancer Institute. She primarily treats patients with gastrointestinal cancers and is actively involved in clinical research trials.

Dr Palta has always liked helping people, and in college volunteered in the oncology ward. She knew then that she had found her passion. Interacting with patients is her favourite part of the job. She likes to explain how radiation works and how it can benefit them. Her hope is to provide her patients with an explanation that gives them less anxiety and less fear about the treatment.

Dr Palta’s primary clinical focus is the treatment of gastrointestinal malignancies. She is the principal investigator of three prospective, investigator-initiated studies. The first seeks to optimize the neoadjuvant regimen for patients with potentially resectable pancreas cancer by incorporating neoadjuvant systemic therapy and stereotactic body radiotherapy (SBRT). The second is an investigator-initiated study evaluating the addition of immunotherapy, pembrolizumab, into the neoadjuvant treatment of resectable esophagogastric cancers treated with chemoradiation. This project involves 2 tumor biopsy and 5 liquid biopsy collections during the trial for tumor immunophenotyping. Lastly, she is conducting a multi-institutional, prospective, randomized phase II study evaluating quality of life differences with liver SBRT or percutaneous ablation in patients with non-operative hepatocellular carcinoma.

Associate Professor Eddie Lau – Austin Health & Peter MacCallum Cancer Centre, Melbourne

Dr Lau is a Consultant Radiologist & Nuclear Medicine Specialist at Austin Health in Victoria and an honorary radiologist at the Peter MacCallum Cancer Centre in Melbourne, Australia. He has academic appointments of Principal Fellow and Clinical Associate Professor at the University of Melbourne. Eddie is a dual trained radiologist and nuclear medicine specialist with more than 15 years’ experience in cancer and multi-modality imaging, including Computed Tomography, Magnetic Resonance Imaging and Positron Emission Tomography. He has over 70 peer-reviewed publications, 6 books/chapters as well as more than 120 presentations on various topics in cancer imaging at national and international conferences. He has received Royal Australian and New Zealand College of Radiologists and National Health and Medical Research Council Project Grants, and is a reviewer for a number of imaging and cancer journals.

Meeting Highlights of particular interest to Radiation Oncologists include:

WEDNESDAY 21 AUGUST

Opening Plenary: Rare cancers, how can we do better?

Co-Chairs: Professor Tim Price & Doctor Lorraine Chantrill

“For too long we have been making small incremental improvements in outcomes for rare gastrointestinal cancers using chemotherapy.  Are there other more biologically intelligent treatments we could be using in this space? Our Opening Plenary will explore cutting edge therapies for these cancers.” – Doctor Lorraine Chantrill

Featuring multidisciplinary presentations by:

Associate Professor Manisha PaltaCombination of radiation and immunotherapy: Fact or fiction. Toxicity versus benefit

“There is strong interest and preclinical data supporting the potential synergistic effects of radiation in combination with immunotherapy. Multiple Phase I and Phase II trials are ongoing. There are apparent overlapping toxicities of these modalities such as pneumonitis and colitis, however, can these potential increased risk for toxicities be managed if disease outcomes are enhanced? This talk will focus on the current status of data surrounding radiation with immunotherapy, potential toxicities associated with this treatment, and the potential benefits of this approach.” – Associate Professor Manisha Palta

And presentations from other Invited Faculty:

  • Professor Christian JobinThe large fingerprint of Intestinal microbiota in cancer
  • Professor Stephen J Wigmore State of the art treatment for biliary tract cancers

“Cholangiocarcinoma is increasing in incidence in Europe and is now a more common cause of cancer death than hepatocellular carcinoma. Biliary tract cancers are rare and difficult to treat often presenting at an advanced stage and being broadly resistant to chemotherapy. In this paper I discuss the challenges that biliary tract cancers present to surgeons and oncologists.  I will discuss modern scientific approaches to identify novel therapeutic targets in cholangiocarcinoma and I will explore the role of the tumour-stromal environment in cancer growth and how this axis may be a potential target for new treatment strategies for cholangiocarcinoma. In addition, I will consider what may be learned form primary sclerosing cholangitis and biliary fluke infection as inflammatory models of cholngiocarcinoma.

I will discuss the results of the BILCAP and ABC06 trials and discuss the design of a new UK –based trial to evaluate the role of neoadjuvant therapy for hilar and perihilar cholangiocarcinoma. Data on the role of liver transplantation for cholangiocarcinoma will be presented and where such treatment might sit within a multimodal approach to this disease. Treatment approaches for gall bladder cancer and the management of incidental gall bladder cancer will be presented.” – Professor Stephen J Wigmore

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Radiation Oncology Workshop: Cholangiocarcinoma

Co-Chairs: Professor Trevor Leong & Doctor Dominique Lee

International Faculty: Associate Professor Manisha Palta

National Faculty: Associate Professor Eddie Lau

“The outcomes for cholangiocarcinomas are poor. Recent interest in exploring new treatment paradigms has seen the emergence of radiotherapy to improve outcomes for patients with cholangiocarcinoma. After a summary of the current imaging modalities in cholangiocarcinomas, this workshop explores the current role of radiotherapy in the management of cholangiocarcinoma. Cases will include radiotherapy in a neoadjuvant, definitive and adjuvant setting.” – Doctor Andrew Oar

Featuring keynote presentation by:

Associate Professor Eddie Lau – Imaging in Cholangiocarcinoma

The role of imaging in both the initial disease extent and post treatment of cholangiocarcinoma, including the strength and limitations of various modalities, as well as their key Imaging features will be discussed and presented. 

Imaging has a role in the detection of primary cholangiocarcinoma, both in defining its local disease extent and metastatic status, especially when surgical resection or ablative radiotherapy is being considered, as well as assessing response post treatment. 

The key radiology imaging modalities are Computed Tomography (CT) and Magnetic Resonance Imaging (MRI), including CT Intravenous Cholangiography (CT IVC) and MR Cholangiopancreatography (MRCP) which are particularly useful in the assessment of the peri-ductal infiltrative cholangiocarcinoma. Positron Emission Tomography with F-18 fluorodeoxyglucose (FDG PET) can be a problem solving imaging tool in case of equivocal metastatic lesions and may aid response assessment. Ultrasound plays a supplementary role, usually as the imaging tool to guide tissue biopsy of liver tumour mass. 

Contrast enhanced multi detector CT, including multiphase images of the liver, represents the primary imaging method for cholangiocarcinoma, with the intrahepatic mass-forming cholangiocarcinoma typically demonstrating a specific enhancement pattern and capsular retraction. The advent of dual energy CT provides the opportunity to obtain virtual precontrast images and has the potential to improve tumour-background contrast and sensitivity. 

Contrast enhanced MRI provides superior soft tissue contrast and is the radiology modality of choice in assessing the extent of liver disease in the appropriate patient, especially when hepatocyte-specific contrast agent and diffusion weighted Imaging are used.  

Response assessment following local ablative radiotherapy can be challenging, requires a good understanding of normal post-radiation changes and use of both morphological and functional imaging techniques.” – Associate Professor Eddie Lau

Followed by case discussions led by:

  • Doctor Mark Lee
  • Doctor Sweet Ping Ng

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Multidisciplinary Workshop: The neoadjuvant approach in operable tumours & other controversies in pancreatic cancer

Chairs: Associate Professor Mustafa Khasraw, Doctor Andrew Oar & Doctor Iain Thomson

International Faculty Panel: Associate Professor Manisha Palta, Professor Stephen J Wigmore & Professor Jim Abbruzzese

National Faculty Panel: Professor Desmond Yip, Doctor Hien Le, Professor Jaswinder Samra & Ms Jan Mumford

Featuring multidisciplinary presentations by:

Professor Stephen J WigmorePros of primary surgery in pancreatic cancer

“Pancreatic cancer is increasingly been considered as an oncological emergency. This widely adopted mantra has been used as a justification for promoting the role of early surgery in patients with pancreatic ductal adenocarcinoma. Surgical resection is known to offer the only real chance of curing PDAC and up until recently many patients and clinicians believed that the sooner that surgery can be undertaken the better.

In patients presenting with obstructive jaundice, the recognition that proceeding directly to resectional surgery was associated with higher resection rates and fewer complications than for patients in whom a biliary stenting, recovery and then surgery approach was taken, has further fueled the argument for early surgery. Further, recent studies looking at the role of emergency jaundice clinics have shown that early identification of patients with PDAC can permit on average a 4 week reduction in the work up time to get patients to surgery and argue that this may reduce stage migration and reduce the rate of local advancement of disease.

Counter arguments to early surgery centre around the fact that tumour biology and stage ultimately determine outcome irrespective of treatment approach and that tumour stage is often underestimated in pancreas cancer. Early surgery may still have a role in patients who do not want or are not able to tolerate neoadjuvant strategies.” – Professor Stephen J Wigmore

Associate Professor Manisha Palta – Pros of neoadjuvant therapy in pancreatic cancer

“The historic approach of upfront surgical resection and adjuvant therapy has resulted in a 5-year survival of nearly 20%. Recent data incorporating adjuvant FOLFIRINOX has demonstrated a dramatic impact on survival outcomes. Given that nearly a third of patients will not receive the intended adjuvant therapy and the high rates of distant metastatic progression, there is renewed interest in neoadjuvant therapy prior to surgical resection. This approach provides a patient and tumor specific testing of biology to ensure that patients selected from surgery are most likely to benefit from a planned operation. Trials evaluating neoadjuvant therapy are ongoing in an effort to clarify the potential benefit of this treatment paradigm.” – Associate Professor Manisha Palta

 And presentations by other Invited Faculty:

  • Professor Jim AbbruzzeseState of the art management of operable pancreatic tumours
  • Ms Kate FurnessEffect of early and intensive nutrition care, delivered via telephone or mobile application, on quality of life in people with upper gastrointestinal cancer

Followed by brief case presentations:

  • Doctor Alexander P DavisMedical Oncology Case Presentation
  • Doctor Sweet Ping Ng – Radiation Oncology Case Presentation

The panel members will give their perspectives, reflect on their practice and their thoughts regarding future directions in this area with an emphasis on clinical trials to address gaps in our knowledge in the arena.

THURSDAY 22 AUGUST

Keynote Breakfast Session: The role of SBRT in oligometastatic gastro-intestinal cancer

Co-Chairs: Doctor Andrew Oar & Doctor Dominique Lee

Presenter: Associate Professor Manisha Palta

“Traditional palliative approaches to patients with early metastatic disease has been an area of active research.  Recent randomised evidence has demonstrated an overall survival benefit for SBRT in oligometastatic disease in non-small cell lung cancer.  To date, no randomised trials have been published exploring SBRT in oligometastatic gastrointestinal cancer. This keynote session will discuss the “Who”, “When” and “Why” of SBRT in oligometastatic gastrointestinal cancers and the opportunity for meaningful research in this controversial domain.” – Doctor Andrew Oar

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Radiation Oncology Workshop: Anal Cancer

Co-Chairs: Associate Professor Andrew Kneebone & Doctor Meredith Johnston

International Faculty: Associate Professor Manisha Palta

National Faculty: Associate Professor Andrew Kneebone, Associate Professor Eddie Lau & Doctor Gina Hesselberg

Anal cancer is a rare disease, but its incidence is rising rapidly. There is a desperate need to improve outcomes as treatments have not changed for nearly thirty years. With advancement of imaging and radiotherapy techniques, the role of personalised treatment is an area of current research.” – Doctor Andrew Oar

Featuring keynote presentation by:

Associate Professor Eddie LauResponse assessment using PET scan, Role of interim PET and 3 month imaging

The role of Positron Emission Tomography imaging with F-18 Fluorodeoxyglucose (FDG PET) in response assessment of anal carcinoma, including the values of early interim 1 month and later 3 month post treatment, will be discussed and presented.

“FDG PET imaging has a role in initial staging and radiotherapy planning of anal carcinoma, with a recent meta-analysis showing FDG PET/CT altered TNM stage in 41% of patients and PET would led to a change in radiotherapy plan (RTP) in at least 28% of patients. Similar results have also been reported in local Australian study, with PET upstaging 15% of patients and changing RTP in 19%. 

Post-treatment FDG PET scan has been shown by multiple studies to provide valuable and prognostic information. A recent French study from Bordeaux showed that FDG PET/CT has a 92% sensitivity in detecting residual disease and a high negative predictive value of 96.4%, changed management in 14% of patients and a complete metabolic response (CMR) was a significant predictor of progression free survival (PFS) and cancer specific survival (CSS) with p<0.0001. An earlier US study from St Louis also showed similar results, with 2-year CSS of 94% for patients with a CMR on PET versus 39% for patients with a partial metabolic response (PMR). A local Australian study also showed similar results, with 5-year overall survival of 88% in CMR, 69% in PMR and 0% in no response cohort.  

Timing of post-treatment PET scan has been assessed by limited studies. An Italian study found that PET/CT at 3 months post-treatment was more accurate than PET/CT at 1 month in evaluating residual disease, with more superior PPV (66% vs 40%) and NPV (100% vs 97.4%). A US study also found more superior PPV and NPV in PET/CT performed between 13-25 weeks post treatment compared to those performed 5-12 weeks. This is in keeping with the ACT II trial results that suggested a later response assessment time point may be more appropriate.” – Associate Professor Eddie Lau

And keynote presentation by:

Associate Professor Manisha PaltaNew approaches for anal cancer – role of dose escalation and individualised radiotherapy (ACT5)

Since the Nigro regimen first published nearly 5 decades, no appreciable alterations have been made in the concurrent systemic therapy regimen of 5-flourouracil and mitomycin-C concurrent with radiation. Over that time period, however, there has been increasing radiotherapy dose escalation from 30Gy first published by Nigro to doses of 6000-7000cGy. A more personalized approach to anal cancer is needed to mitigate the acute and late toxicities associated with radiotherapy. This talk will focus on the current status of anal cancer and ongoing studies to individualize radiotherapy doses through dose escalation and de-escalation in select patients.” – Associate Professor Manisha Palta

Followed by case presentations by:

Doctor Gina Hesselberg

FRIDAY 23 AUGUST

AGITG Upper GI Cancer Research Session

Two AGITG clinical trials involving radiotherapy will be presented in the AGITG Upper GI Cancer Research session along with six other AGITG trials:

  • Professor Trevor LeongTOPGEAR, A randomised II/III trial of preoperative chemoradiotherapy versus preoperative chemotherapy for resectable gastric cancer
  • Doctor Andrew OarMASTERPLAN, a randomised phase II study of MFOLFIRINOX and stereotactic radiotherapy (SBRT) for pancreatic cancer with high risk and locally advanced disease.

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Closing Plenary: Trials and Tribulations in colorectal cancer in 2019

Co-Chairs: A/Prof Michael Jameson & Professor Stephen Ackland

International Expert Panel:  Professor Florian Lordick, Professor Christian Jobin, Associate Professor Manisha Palta & Professor Stephen J Wigmore

“New treatments for colorectal cancer have been sparse in the last few years. Are there other ways we could look at this diverse group of bowel cancers? Our Closing Plenary will look at colorectal cancer through different lenses.” – Doctor Lorraine Chantrill

  • Professor John Simes – 2018 John Zalcberg OAM Award Recipient Presentation on appropriate aspects of his area of interest
  • Professor Peter Gibbs – Registry Trials in CRC and other GI Cancers
  • Professor Christian Jobin – Next challenges in moving from microbiome into clinical integration (opportunities and barriers)
  • Professor Florian Lordick – Hottest topic in colorectal cancer
  • Panel Discussion

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Final Program

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