Several Questions: Stage IV PC with liver mets, on the way of FOLFIRINOX treatment

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Several Questions: Stage IV PC with liver mets, on the way of FOLFIRINOX treatment

by danny4mami on Fri Jan 05, 2018 03:37 AM

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My mum, a Hong Kongese residing in Hong Kong, aged 55, was diagnosed with stage IV pancreas adenocarcinoma in late Oct 2017, with 4 mets at liver. No any other distant metastasis.

The primary tumor is located at head of pancreas, staged T4N1, at the time of diagnosis, with size 32.6mm x 28.5 mm x 39.0 mm, according to PET-CT scan.

At diagnosis, my oncologist listed out the 2 first-line chemo regimen. FOLFIRINOX & Gemzar+abraxane. 

With better statistics of response rate and overall OS, we chose FOLFIRINOX and oncologist recommended this too coz he thought my mum is strong enough to give it a try.

My mum started the chemo treatment immediately after the diagnosis, 1 cycle per 2 weeks, as recommended in the standard of care.

However, the treatment process is not as smooth as initially expected, due to the bone marrow suppression that results in low platelet count.

For the white blood cell count, it seems not a problem coz my oncologist will prescribe Neupogen injections.

But the problem comes from low platelet count - my oncologist said he had no solution to boost up the platelet, except giving my mum a try of Eltrombopag, which he claimed he's not sure if it helps in chemotherapy-induced thrombocytopenia (CIT).

My mum has now just finished the 5th cycle, with the 4th cycle delayed 5 days and the 5th cycle delayed 2 days.

We were quite upset by the delay. But it seems in Cancer Compass I always saw ppl not mentioning the postponement of chemo cycle.

So here's some of my questions.

 

1. Is it common for FOLFIRINOX patient to have delays due to blood cell count? Will such delay have impact on the overall efficacy of the treatment?

2. Any PC patient prescribed with Eltrombopag here for low platelet count? Is it effective on curing CIT?

*******

Besides, tumor markers are strange in my mum's case. She has low CA19-9. 

At diagnosis,

CA19-9 12.1

CEA 172.1

After 3 cycles of FOLFIRINOX,

CA19-9 7.1

CEA 434.1

CA125 841.4

Actually tumor markers are checked every post-cycle period, and CEA and CA125 kept rising, while CA19-9 is so low and stable.

So my oncologist arranged another PET-CT scan after 3 cycles of FOLFIRINOX.

The result is quite positive, showing all tumors are shrinking (though most shrinks are small), with the primary tumor claimed as metabolically N0.

All SUVmax of tumors are lowering too, with some turned "background".

A bit ascite is present - the report claimed "Slightly increased mildly metabolic ascites is consistent with the suspicious microscopic seeding. No sizable FDG-avid peritoneal deposit is found."

I am afraid of presence of ascites. But my oncologist seems does not think it's problematic and said "it may be due to some reaction from the tumors to the chemo".

My questions goes to

3. What does it imply when tumors are shrinking while CEA and CA125 are rising? My oncologist said he had no idea on this too. Any similar case out here?

4. The tumors are shrinking whereas there is "slightly increased mildly metabolic ascites". Is it some sign of disease progression....?

*******

Some more questions:

5. For stage IV PC patients, it seems there are only systemic chemotherapy they can do. Any other possible treatments? e.g. Nanoknife IRE? (I heard that some surgeons / radiologists may do IRE for some stage IV cases) How about SBRT / radiotherapy?

6. According to Dr. Robert Martin, Nanoknife IRE can only be applied to stage III or below patients, coz there is biological difference between stage III and IV disease. What does such difference imply? As far as I know, stage III means no mets are found except the primary tumor. Why is it a biological difference when someone with stage IV PC undergoing chemo to clear all mets can been seen as downstaged to stage III? What makes stage IV not applicable to IRE but stage III can do?

7. To most ppl stage IV PC seems hopeless, but the only cure to them are using systemic chemotherapy for them to downstage. What is the probability of the downstaging for stage IV PC patients with only mets to liver?

8. Drug resistance of chemo sooner or later will occur. But how can an oncologist detect the drug resistance?

Sorry to ask so many questions here. But I guess answers to the questions may help clarify concepts of such deadly diseases to the forum users.

Many thankssss.

Best Regards,

Danny

RE: Several Questions: Stage IV PC with liver mets, on the way of FOLFIRINOX treatment

by danny4mami on Sat Jan 06, 2018 12:13 AM

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RE: Several Questions: Stage IV PC with liver mets, on the way of FOLFIRINOX treatment

by WonderWoman1 on Mon Jan 08, 2018 09:20 PM

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hi Danny, lots of questions!  I learned, researched that markers can flactuate due to the cancers being atatched / dissolving, reacting to chemo, ive heard a lot of people had their markers increase during chemo and drop after treatment, similar to lets say an inflamation response.. i have a good site to ask these type of questions, if your interested, feel free to message me so i can send u the link. 

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