CASE OF ADVANCED PDAC: PROGRESSION BEYOND FIRST LINE AND CARCINOMATOSIS MEENA SADAPS, MD FELLOW, HEMATOLOGY/ONCOLOGY DAVENDRA SOHAL, MD, MPH ASSOCIATE PROFESSOR, HEMATOLOGY/ONCOLOGY DIRECTOR, CLINICAL GENOMICS PROGRAM
CLINICAL CASE ¡ 57 year old male ¡ Initial presentation of 60 lb weight loss + new onset, uncontrolled DM2 ¡ Imaging: pancreatic mass, liver lesions ¡ Liver biopsy: Adenocarcinoma, consistent with pancreatic primary (CK7+, CK20-) ¡ ECOG PS 0
WHAT WOULD YOU DO? A. Best supportive care B. FOLFOX C. FOLFIRINOX D. Gemcitabine alone E. Gemcitabine/nab-paclitaxel
TREATMENT HISTORY ¡ Jun 2017: Started FOLFIRINOX
ASCO GUIDELINES – FOLFIRINOX – 1 ST LINE TREATMENT ¡ Recommendation 2.1 : FOLFIRINOX is recommended for patients who meet all of the following criteria: ¡ ECOG PS of 0 to 1 ¡ Favorable co-morbidity profile ¡ Patient preference ¡ Support system for aggressive medical therapy ¡ Access to chemotherapy port and infusion pump management services
TREATMENT HISTORY - PROGRESSION Oct 2017: Imaging with progression of disease ¡ ECOG PS 1 ¡
NEXT -GENERATION SEQUENCING ¡ Foundation One ¡ No actionable alterations
WHAT WOULD YOU DO NEXT? A. Best supportive care B. KRAS-targeting drug (e.g. MEK inhibitor) C. Non-genomics-driven clinical trial D. Gemcitabine alone E. Gemcitabine/nab-paclitaxel F. Nanoliposomal irinotecan
ASCO GUIDELINES – 2 ND LINE TREATMENT ¡ Recommendation 3.3 : Gemcitabine plus nab-paclitaxel can be offered as second-line therapy to patients who meet all of the following criteria: ¡ 1 st line treatment with FOLFIRINOX ¡ ECOG PS of 0 to 1 ¡ Relatively favorable co-morbidity profile ¡ Patient preference ¡ Support system for aggressive medical therapy
TREATMENT HISTORY ¡ Patient preferred chemotherapy ¡ Oct 2017: Started gemcitabine/nab-paclitaxel
TREATMENT HISTORY - PROGRESSION ¡ Dec 2017: Imaging with progression of disease ¡ Now with rapid clinical deterioration ¡ Cachexia, anasarca, ECOG PS barely 3 – transitioned to hospice
QUESTIONS?
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