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I have a really upsetting case that I think is just a freek thing but I want to see if anyone else has any thoughts.
60 y/o female with an infiltrative unresectable pancreatic cancer. Rather than being a discrete mass, it was more of a sheet of tissue around her celiac and primary branches. She got 6 cycles of FOLFIRNOX and did well then I followed it up with 50.4 Gy to the primary. I know that LAP-007 did 54 but for unresectable patients I generally try to stick closer to 50.4 because I am not convinced 54 is better or worth the added risk of symptomatic bowel toxicity. In her plan the hot spot to the stomach was in the posterior antral wall and was 52.4 Gy (well within tolerance). She was on a PPI during treatment and had essentially no acute toxicity during treatment. Four months post treatment she came in anemic and had a bleeding ulcer in her posterior antral wall (so probably related to her radiation). After multiple interventions she ultimately required a partial gastrectomy because they couldn't control the bleeding. However, a week after surgery her Hb continued to drop and on repeat EGD they found that she had diffuse mucosal bleeding in her residual stomach and duadenum. She refused further intervention and since passed away.
Something is obviously weird. She should have had a very low risk of developing a symptomatic ulcer in the first place but why they couldn't control the bleeding is also odd (she had no known clotting disorders and her nutritional status was fine). Has anyone else had any unexpected severe GI toxicity in patients treated with neoadjuvant FOLFIRNOX? A lot of our patients are getting this and seem to be doing fine and given the good data in PRODIGE etc I am generally supportive of the approach but if other people are seeing anything it might give me pause. Honestly, I think it is probably just a horrible fluke. If we treat enough people we will sadly see these cases.
60 y/o female with an infiltrative unresectable pancreatic cancer. Rather than being a discrete mass, it was more of a sheet of tissue around her celiac and primary branches. She got 6 cycles of FOLFIRNOX and did well then I followed it up with 50.4 Gy to the primary. I know that LAP-007 did 54 but for unresectable patients I generally try to stick closer to 50.4 because I am not convinced 54 is better or worth the added risk of symptomatic bowel toxicity. In her plan the hot spot to the stomach was in the posterior antral wall and was 52.4 Gy (well within tolerance). She was on a PPI during treatment and had essentially no acute toxicity during treatment. Four months post treatment she came in anemic and had a bleeding ulcer in her posterior antral wall (so probably related to her radiation). After multiple interventions she ultimately required a partial gastrectomy because they couldn't control the bleeding. However, a week after surgery her Hb continued to drop and on repeat EGD they found that she had diffuse mucosal bleeding in her residual stomach and duadenum. She refused further intervention and since passed away.
Something is obviously weird. She should have had a very low risk of developing a symptomatic ulcer in the first place but why they couldn't control the bleeding is also odd (she had no known clotting disorders and her nutritional status was fine). Has anyone else had any unexpected severe GI toxicity in patients treated with neoadjuvant FOLFIRNOX? A lot of our patients are getting this and seem to be doing fine and given the good data in PRODIGE etc I am generally supportive of the approach but if other people are seeing anything it might give me pause. Honestly, I think it is probably just a horrible fluke. If we treat enough people we will sadly see these cases.