Eileen M. O'Reilly, MD: How the Treatment Course Aligns With New NCCN Guidelines

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

This gentleman is a very typical presentation of pancreas cancer, a 65-year-old man with metastatic disease involving the liver, lymph nodes, and peritoneal cavity. He has a head of pancreas cancer primary and presented with obstructive jaundice requiring a stent placement.

The treatment option of gemcitabine/nab-paclitaxel is a frontline standard of care. Options on disease progression depend on several things—patient performance status, patient preference, what standard options are available, and what clinical trial options are available.

This gentleman went on to receive what has become a newly recognized standard in a second-line setting or in patients who have had prior gemcitabine. This combination of liposomal irinotecan, 5-FU, and leucovorin was compared to 5-FU and leucovorin on its own and also compared to single-agent liposomal irinotecan.

The triple drug combination showed an improvement in median overall survival of about 6 months compared to about 4 months for 5-FU—based therapy with toxicities such as neutropenia, diarrhea, fatigue, and nausea/vomiting. They were the major toxicities that were observed.

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.