Diagnosis and Treatment of Metastatic Pancreatic Cancer

John Marshall, MD:So, this is a fairly typical case of a patient with pancreatic cancer—66 years old. She presents actually with jaundice and some abdominal discomfort. She gets worked up and found to have, on CT, a pancreas mass, and the mass is big enough that it has now pinched her bile duct. And so, she’s jaundiced, and her labs show that. Her cancer marker is elevated and so she goes to GI. She has an upper endoscopy, an ERCP (endoscopic retrograde cholangiopancreatography) stent is placed, and brushings are taken. At that point, she is diagnosed with pancreatic cancer.

Now, typical imaging is done—usually CT and endoscopic ultrasound is standard—and she’s found that maybe she might be surgically resectable. And so, she heads off to the operating room, and the findings at surgery, unfortunately, are that she has metastatic disease to her liver at that point. And so, the surgeon appropriately opts to not do an operation, sews her back up, and sends her to the medical oncologist.

She shows up a few weeks later, and about a month later, initiates treatment with systemic chemotherapy. And the choice that was made was nab-paclitaxel, or Abraxane, and gemcitabine combination, a 2-drug combination; that gets initiated. She tolerates it pretty well. She has some mild nausea, which is pretty easy to control, and she has some fatigue that is typical of the cancer and the chemotherapy. But she also has a little bit of neutropenia, which is managed through our usual routes, sometimes using growth factor support. She tolerates it pretty well, in general, and undergoes repeat scanning a month or so later. And she actually has a really nice response. Liver lesions are no longer visible and the pancreas mass remains fairly stable. She continues on treatment for a little while longer and eventually develops a complication of some diabetes. She gets admitted to the hospital for that. Not an uncommon problem that we see when we’re beating on people’s pancreases, with chemotherapy, and all of that for them to get some diabetes, lose glucose control. So, in that evaluation, she’s also found to have some progression of disease.

And so, new liver lesions, new-onset diabetes, it’s time to change therapy. And nowadays, of course, we have a variety of choices in second-line therapy. But because of this woman’s age—she’s under the age of 70, good performance status still—the doctor decides to give her full monty chemotherapy of the combination regimen of FOLFIRINOX in the second-line setting. And she’s off that treatment now.

So, this is a fairly typical patient presenting with pancreatic cancer. She has already got symptoms—jaundice, probably some pain, and doesn’t feel right. And this cancer, almost in everybody, brings them down a rung or two on the performance status tier. This patient is no different. Also, being 66, it’s important to recognize that fairly aggressive chemotherapy such as FOLFIRINOX may not be all that well-tolerated and may be difficult to get into her. And so, I put those pieces of the puzzle together and say that this is a good case for gemcitabine/nab-paclitaxel frontline therapy.

You want to ask some other deeper questions, too, about a patient. Lives alone or not? How much support does the patient have? Really, how well are they? What are the other comorbidities? All of that factors into a decision as to how one picks what you’re going to use in frontline therapy.

Pancreas cancer’s terrible. The problem with this disease is it has a very short timeline in terms of overall survival. We are doing better. If a patient really asked and wanted me to pin this down, under 1 year is typical survival. There are a few patients who make it longer than a year with metastatic pancreas cancer. And that’s really coming on the backs of successful first-line, and now second-line, chemotherapy. So, her overall prognosis is not good. There are a few lucky folks—they’re what we call “the tail on the curve”—but there are some on the other end that really never respond to treatment and don’t do well at all.

Transcript edited for clarity.

April 2015

• A 66-year—old female presented to her gastroenterologist with jaundice, weight loss, upper right quadrant abdominal pain, and diarrhea. She continued to carry out normal activity but reported requiring rest on most days.
• CA19-9: 2296 U/ml
• Abdominal CT scan showed an expansive lesion measuring 39 × 26 mm between the pancreas and inferior vena cava, below the portal vein. There was enlarged para-aortic lymph node and stenosis of the common bile duct.
• Endoscopic retrograde cholangiopancreatography was performed and the patient was referred for surgery.
• Explorative laparotomy showed the mass to be inoperable because of local vascular infiltration and liver metastases.
• Pathophysiology confirmed pancreatic adenocarcinoma; stage T4N1M1

May 2015

• The patient was started on gemcitabine + albumin-bound (nab) paclitaxel
• She complained of moderate nausea and fatigue for the first 4 weeks of therapy which was managed with antiemetic therapy
• Neutropenia was managed

August 2015

• CT scan shows stable disease
• CT scan showed no residual liver metastases; the tumor in the head of the pancreas was unchanged in size.
• The patient is asymptomatic and continues to tolerate therapy

June 2016

• Patient hospitalized for high blood glucose levels, diagnoses with new onset insulin-dependent diabetes mellitus
• CT scan showed appearance of several new liver metastases
• The patient was started on the FOLFIRINOX regimen