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In a case-based discussion, Johanna Bendell, MD, describes a 60 year-old women with a good performance status who presents with a mass in the uncinate process of the pancreas and three liver metastases. At presentation, she had developed nausea, vomiting, and abdominal pain.
Once symptoms have been treated, Francis P. Arena, MD, recommends an MRI of the liver and pancreas. To make an accurate diagnosis, tissue from one of the lesions should be collected. Fine needle aspiration is ample to ascertain between an adenocarcinoma and a neuroendocrine tumor; however, if more information is needed, a biopsy is required, notes E. Gabriela Chiorean, MD.
In this scenario, Bendell notes that a biopsy was conducted, since the patient enrolled in a clinical trial. At this point, a number of studies are exploring novel treatments for patients with metastatic pancreatic cancer, notes Bendell. In a phase Ib study, the anticancer stem cell antibody OMP-59R5 was explored in combination with nab-paclitaxel and gemcitabine. Additionally, a number of studies are exploring novel agents in combination with established regimens, notes Ramesh K. Ramanathan, MD.
Outside of the confines of a clinical trial, Ramanathan recommends treatment with a multi-drug regimen, such as modified FOLFIRINOX or nab-paclitaxel plus gemcitabine. The decision of which regimen to use varies from physician-to-physicians, notes Chiorean. However, amongst the panel members the nab-paclitaxel plus gemcitabine regimen is preferred to FOLFIRINOX.
Declines in the marker CA 19-9 can be utilized to determine the best therapy to use, suggests Chiorean. In one study, patients with a CA 19-9 decline of greater than 20% experienced a median overall survival of 13.2 months when treated with nab-paclitaxel plus gemcitabine, states Chiorean.