Treatment of Metastatic Pancreatic Cancer with a Combination of Gemcitabine and 5-Fluorouracil: A Single Center Phase II Study

Gemcitabine-associated DRESS syndrome: A case report

INTRODUCTION

Gemcitabine is a well-tolerated pyrimidine antimetabolite chemotherapeutic that is increasingly utilized to treat non-small cell lung carcinoma, breast, pancreatic, and urogenital cancers. Myelosuppression is a common side effect and skin rashes can be observed. We discuss a case of the exceedingly rare DRESS syndrome, which appeared following Gemcitabine treatment.

CASE REPORT

A 60-year-old patient with pancreatic cancer and liver metastases received therapy with Gemcitabine as a single agent. Fever, itching, and redness started to be reported on the third day of receiving Gemcitabine treatment. The patient's diffuse maculopapular rash steadily got worse, leading to hospitalization.

MANAGEMENT AND OUTCOME

In the patient's physical examination, a high fever, hepatomegaly, and a diffuse macular papular rash were detected, an increase in eosinophils in the complete blood count and peripheral blood. A skin biopsy was performed. It was determined that the patient had Gemcitabine-associated DRESS syndrome. Antihistamines and local steroids were administered. On the fifth day following treatment, skin lesions and eosinophilia decreased.

DISCUSSION

The most common cause of DRESS syndrome, a disorder marked by extensive skin eruption, fever, eosinophilia, and systemic symptoms, is medication use. Infections including HHV-6, EBV, and CMV can occasionally be the reason. Gemcitabine is one of the medications that is frequently used in cancer, and a case was provided because the literature review did not mention Gemcitabine-related DRESS syndrome.

Evaluation of Phase II Trial Design in Advanced Pancreatic Cancer

OBJECTIVES

We evaluated how well phase II trials in locally advanced and metastatic pancreatic cancer (LAMPC) meet current recommendations for trial design.

METHODS

We conducted a systematic review of phase II first-line treatment trial for LAMPC. We assessed baseline characteristics, type of comparison, and primary end point to examine adherence to the National Cancer Institute recommendations for trial design.

RESULTS

We identified 148 studies (180 treatment arms, 7505 participants). Forty-seven (32%) studies adhered to none of the 5 evaluated National Cancer Institute recommendations, 62 (42%) followed 1, 31 (21%) followed 2, and 8 (5%) followed 3 recommendations. Studies varied with respect to the proportion of patients with good performance status (range, 0%-80%) and locally advanced disease (range, 14%-100%). Eighty-two (55%) studies concluded that investigational agents should progress to phase III testing; of these, 24 (16%) had documented phase III trials. Three (8%) phase III trials demonstrated clinically meaningful improvements for investigational agents. One of 38 phase II trials that investigated biological investigational agents was enriched for a biomarker.

CONCLUSIONS

Phase II trials do not conform well to current recommendations for trial design in LAMPC.

Phase II Study of Induction Chemotherapy with Gemcitabine plus 5-Fluorouracil Followed by Gemcitabine-Based Concurrent Chemoradiotherapy for Unresectable Locally Advanced Pancreatic Cancer

Aims and background

To evaluate the efficacy and tolerability of a new treatment approach including induction chemotherapy (CT) and concurrent chemoradiotherapy (CRT) in unresectable, locally advanced pancreatic cancer (LAPC).

Patients and methods

Twenty-four patients with LAPC were enrolled in the study. They first received induction CT consisting of 5-fluorouracil (5FU) (500 mg/m2) and gemcitabine (1000 mg/m2), which were given weekly for 3 weeks of every 4. Patients showing a response or disease stabilization after 2 cycles of induction CT received CRT consisting of external beam radiotherapy (50.4-54 Gy in fractions of 1.8 Gy/day) and gemcitabine (350 mg/m2, weekly for 6 weeks). Patients without disease progression received 2 additional cycles of CT consisting of 5FU plus gemcitabine with the same doses and schedule as given in the induction CT.

Results

After the end of the study, 2 (8%) and 5 (21%) patients showed complete and partial responses, respectively. Five patients (21%) had disease stabilization. The grade 3 and 4 toxicities associated with CT were neutropenia (21%) and thrombocytopenia (4%). The grade 3 and 4 toxicities occurring in patients who received CRT were neutropenia (24%), thrombocytopenia (24%), diarrhea (18%), and nausea (12%). The median progression-free survival for all patients was 6 months (95% CI, 3.6-8.4), and the median overall survival was 11 months (95% CI, 8.16-13.84).

Conclusions

The CRT approach of this study is moderately active and has an acceptable toxicity profile. However, the incor-poration of combination CT into CRT at the present schedule could not produce any additional benefit over CRT alone. Newer agents with more systemic activity are clearly warranted.

Fixed-Dose-Rate Gemcitabine Infusion in Patients with Advanced Pancreatic or Biliary Tree Adenocarcinoma

Aims and background

Gemcitabine is an effective agent in pancreatic adenocarcinoma. Fixed-dose-rate gemcitabine has an interesting biological and clinical rationale, with successful results in previous studies. We conducted a trial to confirm efficacy and toxicity of fixed-dose-rate gemcitabine in patients with pancreatic or biliary tree adenocarcinoma.

Methods

Eligible patients with locally advanced or metastatic pancreatic or biliary tree adenocarcinoma received fixed-dose-rate gemcitabine at a dose of 1500 mg/m2 at a rate of 10 mg/m2/min weekly for 3 weeks every 28 days. Efficacy measures were overall survival, response rate and progression-free survival.

Results

Sixty-two patients were enrolled, and 59 were assessable for response. Seven patients (11.3%) had a partial response, 26 stable disease (41.9%) and 26 progressive disease (41.9%). Median time to progression was 21 weeks and median overall survival, 37.71 weeks. Main toxicities were grade 3–4 neutropenia (45.2%) and grade 2–3 asthenia (54.8%). No toxic deaths were documented.

Conclusions

Fixed-dose-rate gemcitabine has a relevant antitumor activity but with significant toxicity. It represents an interesting schedule and could be combined with other biological or chemotherapeutic agents.