ONCAlert | 2017 San Antonio Breast Cancer Symposium
Pancreatic Cancer Case Studies

George P. Kim, MD: How the Treatment Course Aligns With New NCCN Guidelines

George P. Kim, MD
Published Online:Sep 09, 2016
Larry D, a 62-year-old, presented to his primary care physician with persistent pain in his epigastric region, and was later diagnosed with metastatic pancreatic cancer. 

Metastatic Pancreatic Cancer With George P. Kim, MD, and Eileen M. O'Reilly, MD: Case 1

Metastatic Pancreatic Cancer With George P. Kim, MD, and Eileen M. O'Reilly, MD: Case 1
Metastatic Pancreatic Cancer With George P. Kim, MD, and Eileen M. O'Reilly, MD: Case 2


How would Larry's treatment course align with the recent updates to the NCCN guidelines?

The recent NCCN guidelines take into account the new approved drugs for pancreatic cancer. Remember, historically, we were limited to one drug, that being gemcitabine. Now we have two drugs that have been approved over the last 5 years, that being nab-paclitaxel/abraxane and also, more recently, Onivyde, or nanoparticle liposomal irinotecan.

This patient was treated with abraxane/gemcitabine, then went on to Onivyde and then MM-398, the liposomal irinotecan, and then went on to FOLFOX chemotherapy. The NCCN guidelines recommend that if you’re given gemcitabine-based treatment in the frontline, that second-line, you go on to a clinical trial, or you go on to Onivyde and then MM-398. It’s a category one recommendation. This patient was treated very strictly along those guidelines.

Alternatively, the NCCN guidelines also recommend that if you’re treated with a 5-FU–based chemotherapy, for example, FOLFIRINOX upfront, then you go on to a gemcitabine-based treatment in the second-line or an experimental trial. But that approach can be more challenging due to toxicities that are encountered in the frontline that affect your ability to treat in the second-line, meaning giving oxaliplatin in the frontline with your 5-FU–based treatment and then giving abraxane with gemcitabine-based treatment in the second-line can be very challenging for many patients.

Metastatic Pancreatic Cancer: Case 1

Larry D, a 62-year-old, presented to his primary care physician with persistent pain in his epigastric region, which persists throughout the night. Within the past 2 years, he has developed diabetes and experienced considerable weight loss with signs of depression. 

  • During his visit, jaundice was observed along with periumbilical subcutaneous metastases.
  • Testing revealed an elevated CA19-9 level (2293 U/ml).
  • CT scan showed a large mass on the head of the pancreas, and a subsequent biopsy showed the mass to be adenocarcinoma. Liver and local lymph note metastases were identified.

Larry went on to receive the combination of nab-paclitaxel and gemcitabine as frontline therapy for 5 months:

  • Upon progression, Larry was switched to the combination of liposomal irinotecan, fluorouracil, and folinic acid. Treatment failure occurred after 2.5 months.
  • Larry received FOLFOX as a third-line treatment.
Publications
Copyright © TargetedOnc 2017 Intellisphere, LLC. All Rights Reserved.