Meet The Professors: Pancreatic Cancer Edition, 2016 - Video 170-year-old man with metastatic pancreatic adenocarcinoma (mPAC) has a cardiopulmonary arrest after the third cycle of FOLFIRINOX
3:33 minutes.
TRANSCRIPTION:
DR BROOKS: This was a 70-year-old male who presented with abdominal pain, early satiety, weight loss, was found to have a 5-cm pancreatic mass with extensive hepatic metastasis at presentation. Biopsy showed adenocarcinoma. And he was very reluctant to actually consider any treatment. He was a 70-year-old man. His primary objective was to get through the sailing season. He was a major sailor. He was quite a wealthy guy. And he said, “Can I get through the sailing season?” And we saw a few months, really, before the major sailing season. So I certainly discussed treatment with him. He was actually a good performance status patient, so we discussed FOLFIRINOX. He was reluctant. And maybe in retrospect we should have considered something different. But he was seen on day 9 after first folfirinox by one of my colleagues. And he was complaining of severe pins and needles in both legs going not just in the toes, going up into the legs. Interpreted that day as probable oxaliplatin neuropathy. I saw him when he was due then for the next treatment, and the pain was now like pain in his legs, both legs. And the “duplex” scan showed major venous thromboses in both lower extremities. Both. So he was put on enoxaparin, given a short time. And after a delay, we went ahead with another course of FOLFIRINOX, and he actually tolerated it great. Saw him on the day of course 3. He was feeling great. His symptoms had gotten better. He was optimistic. He was feeling great. Three hours later, while we were still in clinic, he was reporting to the emergency room and died in the emergency room, presumably pulmonary embolism. We did not get a postmortem. DR LOVE: Margaret, any comments about this case and the whole issue of thrombosis in pancreatic cancer? DR TEMPERO: This is a big problem for these patients. Eighteen percent of the patients will get a VTE of some sort. And there have been studies that have shown that with low molecular weight heparin, you can decrease the incidence of VTEs. But because they so rarely cause a serious complication for the patient and because giving yourself injections just adds to the complexity of care, we’ve been reluctant to make it a mandatory part of the management via guidelines and so on. And that includes both — I’m on the ASCO Guidelines for VTE as well as in the NCCN. We did not suggest that anticoagulants be routinely used, prophylactically. But this is a really sad thing, because for whatever reason, either he just was not responding to anticoagulation. And would a filter have helped? Would anything else have helped? I don't know. DR BROOKS: We were so ecstatic, because he was a very reluctant patient to get treatment. And he came in. His symptoms were better. He was feeling better. The nurses were, like, dancing. DR TEMPERO: But these are the cases that the hematologists on our guidelines, they see these and they say, “Why aren’t you treating all of these patients?” But I must say, in routine practice we very rarely see that. |