DR BENDELL: This is a gentleman who presented as we typically see gastroesophageal cancer patients present, with a 6-month history of progressive dysphagia, eventually made his way to his primary care physician, who referred him for an endoscopy. And then when he had the endoscopy, he had a GE junctional adenocarcinoma that was moderately differentiated. He initially had scans, which showed no metastatic disease. So he was put on a neoadjuvant chemoradiation regimen. His particular regimen used 5-fluorouracil/carboplatin and paclitaxel, neoadjuvantly. He was taken to the operating room, where he had resection of his disease, which showed microscopic disease remaining in 1 out of 6 lymph nodes, was still positive.

DR LOVE: Then what?

DR BENDELL: So he did well for 14 months, and then he was found to have lung nodules on restaging scans. And so at that point, they sent off HER2 testing. And the HER2 came back IHC 3+ and, also, confirmatory FISH-positive. And so he started on FOLFOX plus trastuzumab as his initial chemotherapy. And he had a PR. But then he started to have issues about 4 months into treatment with thrombocytopenia, so the treating physician had modified the regimen to an infusional 5-FU plus trastuzumab. And eventually, the patient did progress, but after 15 months of therapy.

DR LOVE: Any comment on the — we’re actually doing a survey right now. I was kind of curious about this issue of oxaliplatin thrombocytopenia. How low did his platelets go, and what’s your experience with that?

DR BENDELL: He actually went into the 75,000 range. And that’s about where I typically see it. And I see it in colon cancer patients as well. They usually don’t get as low as 50, but sometimes we start to modify things before that point. What I also worry about with oxaliplatin and continuation is that then if their platelets get low enough, they never seem to really recover again. And then that makes it harder for them to get on trials.

DR LOVE: So bring us up to date on this man.

DR BENDELL: So, interestingly — and this is apropos to Randy — we had a trial when he came to me of trastuzumab plus lapatinib that we were able to get him on. And I actually saw him last week. He’s doing beautifully. He’s continuing on 14 months, had an initial PR and now has stabilized out and feels wonderful.

DR LOVE: So, speaking of fun drugs…because as you’ve kind of alluded to, lapatinib kind of — since some of the newer anti-HER drugs have come in, people are looking a little bit differently toward lapatinib in terms of toxicity — but how did he do with the lapatinib in terms of GI or skin?

DR BENDELL: His biggest toxicity is he does have some diarrhea, but it’s very manageable. It’s Grade I/II. He takes a loperamide when he has his diarrhea. He also has this funny maculopapular skin rash on his forearms, which continues to itch consistently. And he has one paronychia on his great toe, which we’ve been treating with antibiotics here and there. But, otherwise, continues to golf and do yard work.

DR LOVE: I’m just kind of curious. He’s behaving like a lot of patients with breast cancer in terms of the longer response. Maybe he’s more of an outlier in terms of gastric. I don't know. But if you were to go back and see him in clinic on Monday and he had progressive disease, what would you be thinking about?

DR BENDELL: So for him, I’d be thinking about taxane-based therapies. I’d be thinking about other clinical trials, which I think we’re going to talk about here, which he probably would not be a candidate for. But starting to talk about some of these other anti-HER2 agents for breast cancer.

Colorectal cancer

Gastric cancer

Pancreatic cancer

Hepatocellular carcinoma

Gastrointestinal neuroendocrine tumors

Gastrointestinal stromal tumors