Meet The Professors: Pancreatic Cancer Edition, 2016 - Video 3385-year-old man who was diagnosed with localized pancreatic cancer develops hemolytic uremic syndrome after receiving adjuvant chemoradiation therapy including gemcitabine
4:02 minutes.
TRANSCRIPTION:
DR SCHWARTZ: So, this gentleman is 85 and in good health. In 2004 at age 73, he was diagnosed with a localized pancreas cancer, a T3N0. He underwent surgery and had an R0 resection. And back then, we elected to give him adjuvant radiation with capecitabine, which he tolerated well, and then I put him on gemcitabine as additional adjuvant therapy. Again, this was back in 2004. I’m not sure what I was basing those regimens on. And then after several months of treatment, he developed hemolytic uremic syndrome. DR LOVE: Can you talk a little bit about exactly what happened when he developed the hemolytic — DR SCHWARTZ: Yes. He was admitted to the hospital. He had hypertension, renal insufficiency, thrombocytopenia, which is tough on gemcitabine, because everybody gets some. But he also had, clearly, histocytosis and an elevated LDH. And so he met the criteria need for — DR LOVE: How was he managed? DR SCHWARTZ: So back then we elected to manage him in a way that I wouldn’t do today. We’d used plasma exchange. And now I think it’s pretty clear that that’s not necessary, that it’s a cumulative drug-induced toxicity. And you just support them. But we did plasma exchange and a lot of support. And he got through it eventually. It was a prolonged course but eventually improved to the point where now I see him solely for his once-a-month erythropoietin injection for his anemia related to his leftover renal insufficiency. DR LOVE: What’s his current renal function and blood count? DR SCHWARTZ: So his creatinine is around 2. DR LOVE: How about his white count and platelets? DR SCHWARTZ: White count’s normal. Platelets run around 100,000. DR LOVE: So Margaret, any comments about this case? DR TEMPERO: This is reported. It’s rare, and it’s probably idiosyncratic, not dose related. You described, adequately, what we do now is basically support the patients and stop the gemcitabine. There’s no way that you can resume it under those circumstances. DR BEKAII-SAAB: So I’ve actually seen it a few times, very unnerving, over the last few years. The more you treat patients, the more you’re going to see it. For whatever reason, when it became genetic we had like a splurge of them. And I say that meaning a couple of them, which is unusual. But we actually support those people. We treat those patients with daclizumab. And they actually reverted back and were able to continue. These were metastatic patients, and we were able to treat them. In fact, interestingly, 1 patient went back on gemcitabine after failing 3 or 4 other lines of therapy, and she was off daclizumab. I mean, after she reverted back. And she didn’t show any signs of HUS with rechallenging gemcitabine. We’re about to report that data. But it was very interesting to see that, I mean, this was a healthy patient, went through the whole gamut. And she had, initially, gemcitabine in the adjuvant setting before she progressed to metastatic disease. This is when she had the HUS, was treated with supportive daclizumab, I think we went through gem/nab, FOLFIRI before nal-IRI was approved, then, FOLFOX. And this took about a year and a half plus in the metastatic setting. And then we ended up with no options, so I actually went back — she was off daclizumab — went back to gemcitabine plus cisplatin. And she went through 4 months of it and ultimately progressed. |