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Ongoing programs

Selected Clinical trials:

Stereotactic Body Radiotherapy (SBRT) for organ-confined prostate cancer

There is evidence from radiobiological studies that prostate cancer is more sensitive to radiation damage compared to the surrounding normal tissues when radiotherapy is given in large doses per treatment. We thus hypothesize that delivering the radiotherapy in an vastly reduced number of highly accurate, focused high-dose treatments will be as safe and efficacious as the current standard of a 37-treatment course. The radiation therapy is to be delivered using intensity modulated radiotherapy (IMRT) with the aid of volumetric image guidance to ensure accuracy. The primary aim is to assess the acute and late toxicity and secondarily Prostate Specific Antigen (PSA), clinical and quality of life outcomes of an extreme hypofractionated regimen delivered using stereotactic techniques for low risk prostate cancer.

Somatostatin receptor imaging in nasopharyngeal cancer

Recently, there have been reports of the expression of somatostatin receptors in nasopharyngeal cancer. Somatostatin is a peptide that functions as a neurotransmitter in the central nervous system and acts as a regulator of endocrine and gastrointestinal functions. Somatostatin receptors are not only found in normal tissues, but are over expressed in certain tumour tissues such as neuroendocrine tumours. Interestingly, NPC has been found to have moderate to high expression of somatostatin-receptor-2 (sst2) in about 75% of patients. This opens up potential therapeutic and diagnostic applications for somatostatin receptor imaging and radionuclide therapy in NPC. Current methods for investigation of NPC utilize computer tomography (CT),magnetic resonance imaging (MRI) and fusion imaging using (18)F-fluorodeoxyglucose (FDG) with positron emission tomography and CT (PET/CT). Though these investigations have high sensitivity and specificity, in pre-treatment cases, in the post-irradiated setting difficulty often arises in detecting both local and regional recurrences. This is due to the similar imaging appearances of inflammatory tissues and recurrent tumour in the head and neck region.

Octreotate is a somatostatin analogue found to be useful in the imaging of neuroendocrine tumors when combined with Galium-68 through a linker DOTA (1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid). Mainly used in the imaging of neuroendocrine tumors, Galium-68-DOTATATE imaging may be useful in overcoming several of the current imaging difficulties in NPC and in addition has the potential to be used in peptide receptor radionuclide therapy as well. With Ga-68-Dotatate imaging, it may be possible to select patients with recurrent/metastatic tumors with high levels of SST2 that may have the option of peptide receptor radionuclide therapy using Lutetium-177 Dotatate. This is currently being done and found to be very effective in neuroendocrine tumors.

Randomised Phase II and Phase III Studies of Individualized Treatment for Nasopharyngeal Carcinoma Based on Biomarker Epstein Barr Virus (EBV)

Deoxyribonucleic Acid (DNA) (NRG-HN001)

Plasma EBV-DNA can been used to monitor recurrence after definitive therapy and multiple studies have demonstrated poorer prognosis in patients with persistently detectable post-radiation plasma EBV-DNA. The current proposal seeks to use plasma EBV-DNA as a biomarker to select the most appropriate candidates for adjuvant chemotherapy after concurrent chemoradiation.

In this proposed trial, post-chemoradiation plasma EBV DNA will be used for risk stratification, and patients will be randomized to different treatments based on their risk. Those who have an undetectable post-treatment EBV DNA level are considered good risk and will be randomized to either observation or the current standard cisplatin and 5-FU. The aim is to see if omitting adjuvant chemotherapy for a group of patients at low risk for treatment failure will compromise overall survival (OS). Patients whose EBV DNA is detectable will be randomized to receive current standard adjuvant cisplatin and 5-FU versus gemcitabine and paclitaxel to test whether the latter regimen can further improve PFS in this high-risk population.

Radiation for Chordomas and Chondrosarcomas

Chordomas are malignant tumours arising from the embryonic notochord remnant with the majority of these tumours occur along the craniospinal axis: 50% grow in the sacrococcygeal regions, 35% in the base of the skull and 15% in the spine. Chondrosarcomas are malignant tumours that arise from cartilaginous structures, typically in the bones of the shoulders and pelvis but can also affect the limbs. About 5% of chondrosarcomas arise in the clivus, parasellar area and cerebella-pontine angle. These are rare tumours and there are no randomized clinical trials and no large prospective series that define the optimal treatment for either disease. Literature reviews of small retrospective series support a combined modality approach using maximal surgical resection and radiation therapy (RT). However, conventional photon radiotherapy in the treatment of chondrosarcomas has shown poor results in terms of local control. The maximum delivered dose ranges from 50 to 60 Gy using such techniques because of the sensitivity of critical organs surrounding the target. Advance RT techniques have improved on spatial selectivity, inverse dose profile with steep dose gradients makes it possible to deliver treatment dose to the tumour while preserving the surrounding organs at risk. The present prospective study aims to study patients with chordomas or chondrosarcoma with respect to treatment toxicity, clinical outcomes, quality of life (QOL) and comparative effectiveness including costeffectiveness of the different treatment strategy.

Outcomes Research in DRO Cancer Care

Individualised medicine based on the twin tenets of Multi-Disciplinary Care (MDC) and Evidence Based Medicine (EBM) has been instrumental in advancing oncology care in the last half-century. However, outcomes research supporting these philosophies of oncologic care is scarce which is ironic as we are neither individualizing it to the Singaporean population nor do we have local evidence in support of the success of this practice.

We aim to create a centre-wide database of all cancer patients treated with radiotherapy in NCCS to ascertain the outcomes of these patients and to benchmark ourselves against other Global leading cancer centres. This database will be updated in perpetuity so that changes in epidemiology, outcomes and impact of various intervention programmes can be tracked. This database will provide up to date information for medical practitioner, policy maker, healthcare administrator, decision maker and educator to make informed decisions on healthcare practise, policies and programmes.

Intratumoral PD-L1 expression and Tumour infiltrating lymphocyte density in Oesophageal cancer treated with Neoadjuvant chemoradiation (PLuTON)

Oesophageal cancer is the eighth commonest cancer in the world and is associated with poor survival even after curative treatment. Preoperative chemoradiation has been shown to improve survival compared to surgery alone. Nonetheless, disease relapse occurs in a significant proportion of patient after chemoradiation and surgery. Early evidence suggests that oesophageal cancer expresses a protein called the PD-L1 receptor which could be a related to poorer outcome in this disease. Immunotherapy such as anti-programmed death 1 (PD1) therapy has improved outcomes in melanoma and non-small cell lung cancer, and may have similar therapeutic benefit in oesophageal cancer. However, preoperative chemoradiation and chemotherapy seem to exert an opposite effect on PD-L1 expression in oesophageal cancer. Besides PD-L1 expression, white blood cells within the cancer called the tumour infiltrating lymphocytes (TILs) is also an indicator of tumour immunogenicity. Hence, we aim to evaluate the changes in PD-L1 expression and TIL density after preoperative chemoradiation in oesophageal cancer as these have the potential to direct future use of immunotherapy in this setting. Patients who are planned for preoperative chemoradiation followed by surgery for resectable oesophageal cancer will be approached for this study. Pre-treatment oesophageal biopsies and resected tumour specimens will be obtained for analysis and stained for the following protein markers: PD-L1, CD4, CD8 and FOXP3. The PD-L1 scores, and TIL density will be assessed by experienced pathologists. Pre-treatment and post-treatment values will be compared and correlated with pathological tumour response. This pilot study will provide valuable information if adjuvant immunotherapy has a role in the management of localised oesophageal cancer in our local population.

Continuous positive airway pressure (CPAP) for respiratory motion management in radical lung radiotherapy

Lung radiotherapy is challenging due to tumour motion from respiration as well as radiotherapy dose limitations due to lung volume constraints. We aim to study the use continuous positive airway pressure (CPAP) during radiotherapy CT simulation in reducing treatment volumes and normal tissue doses thus improving on the radiotherapy treatment plans.

It is important to deliver accurate and precise doses during lung radiotherapy to reduce normal tissue toxicities. There is no optimal standard to deliver lung radiotherapy. Several methods are available, but these can be technically complicated and expensive to implement. CPAP is inexpensive and easy to operate and has been safely used for many conditions. Its use in lung radiotherapy is not well characterized. This study is important as it will help determine if CPAP is beneficial for lung radiotherapy and assess which patients are most likely to gain from its use


Novel Functional Imaging Technique with FLT-PET/MRI For Staging, Response Assessment and Radiation Treatment Planning in Cervix Cancer

This pilot study aims to monitor early tumour response based on [18F]FLT-PET/MRI scans and to determine the feasibility of personalised radiotherapy to spare active bone marrow areas identified by [18F]FLT-PET/MRI.

Phase 2 study of Dose-Reduced Consolidation Radiation Therapy in Patients with Diffuse Large B-cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL), the most common type of NHL and comprises of a heterogeneous group of neoplasms with multiple morphologic variants and subtypes described in the current WHO classification.
As long-term outcomes in DLBCL are becoming more favorable, decreasing the risk of late effects is critical. The risk of complications related to RT, including cardiac disease and secondary cancers, appear to be related to both dose and volume. The rationale would be to lower the dose to maintain efficacy and lower toxicity.

The aim of this phase 2 study is to evaluate whether a reduction in the dose of consolidation RT in patients who achieve a negative post-chemotherapy PET-CT scan following 3 to 6 cycles of chemoimmunotherapy, will be associated with a low risk of in-field failure. The goal of this approach is to maintain excellent control rates while minimizing the risk of acute and late toxicity.

Selected Medical Physics Research Programmes:

Simulation programme for Proton Therapy
The use of well-crafted physics or mathematics-based models to simulate how charged particles & photons transfer energy in a human body plays an important role in Proton Therapy. This, in turn, can lead to a better understanding of and thus improvements to the effectiveness of radiation treatments. In NCCS, this programme is initiated & directed by a team of Medical Physicists. The main computational toolkit is the GEANT4 Monte Carlo suite. Projects in this programme include simulation of charge collection of a new commercial Bragg Peak Chamber for commissioning of our Proton Therapy machine; Simulation studies to commission proton range shifters; Studies on the different models of radiobiological effectiveness (RBE) of Proton Therapy; Independent dose calculation tool to credential Commercial treatment Planning Systems.

Radiomics programme for clinical outcomes prediction
Radiation Oncology is a natural platform for acquiring huge volumetric patient imaging data. The most common form of imaging is CT, MRI and PET which is acquired during pre-treatment. Radiomics is a field focused on extracting multi-dimensional features from images and are subsequently used to build prognostic models to predict either survival, response or other clinical outcomes. It requires knowledge of data analytics, Machine Learning and Image Processing and Physics. There are two main directions to our radiomics research. The first involve collaborating with clinicians to use radiomics approach to predict outcome in brain, NPC and breast. The second focuses on the technical development of radiomics approach to improve the prognostic power and robustness of the model.

SRS programme to quantify & enhance accuracies in Sterotactic Radiosurgery
In Stereotactic Radiosurgery (SRS), is a radiation therapy technique used to treat functional abnormalities and small tumours of the brain. It can deliver precisely-targeted high-dose radiation to target the diseased area, thus can help preserve healthy tissue. Its performance is analogous to surgery but non-invasive. On-going development projects to enhance SRS treatment in NCCS includes introducing the Elements treatment planning system for multiple brain metastasis treatments; integrating the use of 3D volumetric CBCT & 2D imaging with surface guided imaging to achieve high precision patient positioning while reducing imaging radiation to the patient; developing an in-house simulation software system to explore new techniques for SRS treatment.

Proton imaging programme for improved accuracies in Proton Therapy
Using protons to image a patient is set to become a standard of care in Proton Therapy. Currently treatment plans are calculated on X-ray based CT imaging which introduces inherent inaccuracies during calculations of energy losses in protons due to its inability to resolve elemental differences in materials. Imaging in the form of Proton CT or Proton Digital Tomosynthesis can significantly reduce such uncertainties. This programme leverages on software tools built from the Proton Therapy Simulation programme, together with its own hardware and firmware capabilities, to investigate & design novel detectors for proton imaging.

Clinical Collaboration in Ocular Radiation Therapy
Ocular tumours cause loss of vision and the development of an inflamed and painful eye. Malignant tumours also threaten patients with death from local spread or metastatic disease. Ionising radiation is highly effective for treating ocular tumours, thus conserving the eye with as much useful vision as possible while eradicating any risk to life. In late 2018, through a collaboration with Singapore National Eye Centre’s (SNEC) Retina Centre, NCCS Division of Radiation Oncology delivered its 1st ocular brachytherapy in the country, and is only the 2nd clinic in Southeast Asia to provide this operation. To date, the group has treated more than 5 cases of ocular disease, using radiation sources such as Iodine-125 and Ruthenium-106.