Meet The Professors: Pancreatic Cancer Edition, 2016 - Video 2966-year-old man who was initially diagnosed with Stage I pancreatic cancer experiences disease recurrence in the liver and lungs 6 months later
5:42 minutes.
TRANSCRIPTION:
DR BEKAII-SAAB: So this is a 66-year-old gentleman who was initially diagnosed with a Stage I pancreas cancer with a T2N0, went through a Whipple procedure and 6 months of gemcitabine, which was completed in November 2013. And the patient did well and then started becoming symptomatic, some abdominal pain, weight loss, found on a scan to have recurrence in both the liver and the lungs in May 2014. So that’s a little bit less than 6 months or actually 6 months after completing gemcitabine. DR LOVE: So just real quick, Margaret, you get this as an email case, “I’ve got this 66-year-old man,” da, da, da. First impression, what would you be thinking? DR TEMPERO: The patient recurred fairly soon after — DR BEKAII-SAAB: A little bit more than 6 months. So 6 and a half months. DR TEMPERO: It’s not kind of on the fence, in my mind, about whether that patient would be sensitive again to a gemcitabine-based regimen. So it would push me probably a little closer to a fluorinated pyrimidine-based regimen. DR LOVE: So what happened? DR BEKAII-SAAB: So I decided then that — 6 months is what I am still relatively comfortable with reinitiating gemcitabine. And I went with gemcitabine and nab paclitaxel. I went with a biweekly regimen, so every other-week gemcitabine and nab paclitaxel. And the patient actually responded very well symptomatically, improved significantly, had a drop in the CA 19-9 and an actual partial response. DR LOVE: On imaging? DR BEKAII-SAAB: On imaging, yes. And his disease remained under control until November, December 2015, so really a quite solid response, and through all this time was continuously on this biweekly regimen, no neurotoxicity, a little bit of fatigue but mostly tolerable. The patient had a really decent quality of life. DR LOVE: What’s the likelihood that you see this with nab/gem, let alone that he’d had the prior gem? But just, say, in a naïve patient, what’s the likelihood that you would see this kind of scenario, objective response for a while? DR BEKAII-SAAB: About 20% to 25% of the patients will actually have a bona fide objective response, a shrinkage. I’ve seen actually 1 complete responder in my whole usage of the regimen, but that was a patient with very little disease. But you do see about 25%, 20% to 25% response with this regimen. DR LOVE: So let’s again go back to Margaret for choice of second-line therapy. What happened? DR BEKAII-SAAB: So he progressed in December 2015, and then he was treated with — DR LOVE: Hold on before you say. I want you to present to Margaret what was going on. What was going on at that time when you say he progressed? It was all imaging? DR BEKAII-SAAB: No. So what happened is, around October/November 2015, clinically the patient started developing some additional pain, started to lose some additional weight, got a little bit more fatigued. So we started suspecting this, his disease was likely progressing. CA 19-9 in November just trended a little bit up, so it started going in the wrong direction, although the scan in October 2015 still looked stable. But symptomatically, the patient was — at least looked like he was on a path of progression, which, indeed, in December 2015 when we got the next scan, there was progression of the disease in the liver and the lungs. DR LOVE: So Margaret, what would you be thinking at this point? DR TEMPERO: He’s kind of back into that category where you want to use a fluorinated pyrimidine. And it would make sense to use 5-FU and leucovorin and liposomal irinotecan. DR LOVE: So what actually happened? DR BEKAII-SAAB: And that’s what he received. So he received infusional 5-FU and nanoliposomal irinotecan, and his disease stopped progressing. So he had disease stable, maybe a minor response. And his CA 19-9 levels actually dropped by about 30%. And that actually was short lived, lasted until April 2016. So his first scan looked relatively good. And by April 2016, he started again losing more weight. More pain. And at that time, a CT scan again shows progressive disease in the lung, in the liver but also some additional peritoneal metastases. And his performance status was about 2 at that time. DR LOVE: And I know he died shortly thereafter. What were the primary palliative issues in this man? You mentioned he had pain. Was that the main problem, or what was it? DR BEKAII-SAAB: So it’s primarily pain. All these patients universally will get cacxhexia, so they lose significant weight. And at that stage, I mean, you can clearly see a man that was — complete loss of the temporal muscles. I mean, you can see sunken “tempes” and weakness from mostly muscle loss. So when these patients lose weight, they lose muscle more than anything else — thus the weakness. Malnutrition is universal, but unfortunately, given the dynamics of the cancer, additional what I call forced nutrition is unlikely to reverse the pattern of weight loss. And so most of the supportive care in this patient was essentially controlling the symptoms of pain. |