The Benefit of Liposomal Irinotecan in the Treatment of Pancreatic Cancer in a Young Patient – A Case Study
Pancreatic tumors continue to be a challenge in modern oncology. Due to the asymptomatic nature of early stages, most cases are diagnosed in advanced stages. The five-year survival rate of patients does not even reach 10%, and up to half of patients with metastatic pancreatic cancer never make it to the second line of systemic therapy due to the rapid deterioration of their overall clinical condition. In a case study from her own practice, Dr. Marie Beneš Kočová from the Oncology Department of České Budějovice Hospital shared her experience with the treatment of a relatively early-detected disease in a young patient.
Case Description
Diagnosis and Primary Resection
A previously healthy 43-year-old man presented with abdominal pain and subicterus. Computed tomography (CT) and biopsy revealed a ductal carcinoma measuring 2×3 cm in the head of the pancreas. Due to the absence of distant metastases, a duodenopancreatectomy, splenectomy, and hepatomesenteric bypass were performed in April 2021. The tumor was classified as pT2pN0(10/0)M0, G2, and the radical surgery resulted in an R0 resection, with good recovery.
Adjuvant Treatment
In May 2021, a planned six-month course of adjuvant chemotherapy with the mFOLFIRINOX regimen was initiated. However, the patient tolerated it poorly, requiring two hospitalizations due to anorexia and limited oral intake. The fifth cycle had to be delayed due to neutropenia, and the dosage was reduced to 75%. Due to ongoing hematotoxicity, the subsequent 7 cycles of chemotherapy were administered using the FOLFIRI regimen, which the patient tolerated significantly better.
Disease Progression and First-Line Palliative Treatment
A total of 12 cycles of adjuvant therapy were administered, but at the control CT scan upon completion in December 2021, peritoneal infiltration and a hypodense mass near the celiac trunk were detected. Palliative chemotherapy with a combination of nab-paclitaxel and gemcitabine was initiated. The chemotherapy was reasonably well tolerated, and disease stabilization was achieved by March 2022. The nab-paclitaxel dose was later reduced by a quarter due to nonspecific lower limb pain with swelling. After 30 treatment cycles, the patient developed dizziness and right ear deafness, diagnosed as chemotherapy-induced ototoxicity. Symptoms were partially relieved with prednisone and betahistine.
Second-Line Treatment
In September 2022, CT showed progression of peritoneal involvement in the mesogastric and hypogastric regions, with a stationary hypodense retroperitoneal mass. In October 2022, second-line treatment with a combination of pegylated liposomal irinotecan, leucovorin (LV), and 5-fluorouracil (5-FU) in full doses was initiated, along with standard antiemetic prophylaxis. Due to nausea and vomiting, antiemetic therapy was enhanced with palonosetron and aprepitant from the second cycle onwards. The patient also developed grade 3 diarrhea, necessitating postponement of the third cycle and replacement of loperamide with racecadotril, which had good efficacy.
From the fourth cycle, the dose of liposomal irinotecan was reduced to 50 mg/m², and antiemetic medication was further enhanced with olanzapine. With this premedication, the patient tolerated treatment well. After the sixth cycle, the patient experienced cholangitis with obstructive jaundice, successfully treated with endoscopic retrograde cholangiopancreatography, balloon dilation, and antibiotics.
In January 2023, CT scans showed stable findings, and it was decided to continue treatment with liposomal irinotecan at a reduced dose in combination with 5-FU/LV. Antiemetic prophylaxis with aprepitant, palonosetron, and olanzapine resulted in excellent tolerance of the following six cycles of treatment.
Need for Termination of Therapy
In April 2023, the retroperitoneal mass remained stable, and partial regression of carcinomatosis was observed. Consequently, five additional treatment cycles were administered. However, prior to the 18th cycle, the patient became significantly anemic and in poorer general condition. Gastroscopy, conducted due to acute abdominal pain and intermittent blood in the stool, revealed peptic ulcer disease in the esophagus and stomach. The dose of pantoprazole and analgesics was increased, and blood transfusions were administered. The patient's clinical condition improved, and chemotherapy resumed in August 2023 with the administration of the 18th cycle. However, the treatment was poorly tolerated, and the patient's performance status deteriorated. Ultrasound and CT scans revealed metastatic liver involvement.
Liposomal irinotecan treatment was discontinued, and the patient was referred to palliative care. As of November 2023, the patient was still alive, receiving home care with gradually increasing analgesic treatment.
Conclusion
A young patient with pancreatic cancer in good performance status, following radical surgery and adjuvant therapy, received first-line palliative treatment for metastatic disease (gemcitabine/nab-paclitaxel). According to current recommendations, second-line systemic treatment with a combination of pegylated liposomal irinotecan and 5-FU/LV was administered for nearly 11 months. Although the therapy had to be temporarily halted after the sixth cycle due to infectious complications, it significantly extended the patient's overall survival and time to disease progression. A total of 18 cycles of second-line therapy were administered.
Sources:
- Beneš Kočová M. Benefit of Pegylated Liposomal Irinotecan in a Young Patient with Pancreatic Cancer – A Case Study. Oncology Review 2024; 11 (1): 84–88.
- Pancreatic Neoplasm (C25). In: Kiss I. (ed.). Blue Book of the Czech Oncological Society, 30th Update. Masaryk Oncology Institute, Brno, 1 March 2024. Available at: www.linkos.cz/files/modra-kniha/23/897.pdf
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