Le traitement néo-adjuvant du cancer du pancréas borderline ou localement avancé par Eric...

Letraitementnéo-adjuvantducancerdupancréasborderlineou

localementavancé

Prof.EricRAYMONDChefdeserviced’oncologiemédicale

HôpitalSaint-JosephParis14ème

SOIREEDIGESTIVEdeSAINTJOSEPHMardi23mai2017à20h

Salle de conférenceBâtiment Notre Dame de Bon secours

Porte 10 - Niveau -1

Lecancerdupancréas

Le cancer du pancréas (adénocarcinome) est au 10ème rang des cancers les plus fréquents et garde un mauvais pronostic le plaçant au 5ème rang des causes de décès par cancer

L’incidence du cancer du pancréas est en forte augmentation. Chez l’homme, le taux d’incidence annuel standardisé (100 000 homme-années) est passé de 4,9 cas à 9,5 cas entre 1980 et 2015 et chez la femme de 2,0 cas à 6,3 cas sur la même période

Il s’agit d’un cancer agressif souvent d’emblée métastatique et provoquant rapidement une jaunisse, des douleurs et une altération importante de l’état général avec fatigue, amaigrissement et perte d’appétit. Il s’accompagne fréquemment de complications thromboemboliques, inflammatoires, métaboliques et immunologiques jouant un rôle important dans l’évolution des malades

Lecancerdupancréasestleseulcancerdontlamortalitéaugmentedanslesdeuxsexes

Tauxdemortalitédescancerdupancréascomparésauxautrescancers12

Lecancerdupancréasestactuellementla4èmecausedemortalitéparcancerenEurope12

Homme Femme60

40

30

20

10

0

50

1970 1980 1990 2000 2010 2020 1970 1980 1990 2000 2010 2020

20

15

10

5

0

Décèsp

our1

00,000pop

ulation

Poumon

Colorectal

Prostate

Leucémie

Pancréas

Estomac

Poumon

Sein

Colorectal

Estomac

Utérus

Leucémie

Pancréas

12..Malvezzi 2014.Annals ofOncology.European cancermortality predictions fortheyear 201425.Pancreatic Canceractionnetwork.2012.Thealarming rise ofpancreatic cancerdeaths intheUnitedStates:Why we need tostemthetide today

Lecancerdupancréasseraresponsabledeplusdedécèsquelecancerduseinen2020

MortalitéparcancerdupancréasauxUSAcomparéeauxautrescancers25

2010 2020 2030

20

15

10

5

0

poumon

Pancréas

SeinColorectalProstate

25.Pancreatic Canceractionnetwork.2012.Thealarming rise ofpancreatic cancerdeaths intheUnitedStates:Why we need tostemthetide today

Estim

ationde

scancersparm

illiers

Lestauxdesurvieducancerdupancréasn’ontpaschangéconsidérablementdepuis40ans

SurvieparcancerdupancréasenAngleterre13

Alorsquelasurviedelaplupartdescancerss’estamélioré,celleducancerdupancréasrestetrèsbassedepuis40ans13

1971-1975 1976-1980 1981-1985 1986-1990 1991-1995 1996-2000 2001-2003 2003-2007 2004-2008 2005-2009

90

80

70

60

50

40

30

20

10

0

Survie(%

)

52

21

2

2731

12

85Sein

44Leucémie

3Pancréas

58Vessie

82Prostate

43Ovaire

13.CancerResearch UK.Cancersurvival statistics.http://www.cancerresearchuk.org/cancer-info/cancerstats/types

Lecancerdupancréasesttardivementprisenchargeetd’autantplusdifficileàtraiter

14.Oberstein 2013.Therapeutic advances ingastroenterology.Pancreatic cancer:why is it so hardtotreat

Lessymptômessontpeuspécifiquesetretardentsouventlediagnostic

Iln’existepasdebiomarqueur,degèneoudenouvelletechniqued’imageriediagnostique

Latumeurestsouventmalsituéeauconfluentdenombreusesstructuresanatomiques

Lesmétastasessontprécocesmaisdifficilesàidentifier

L’évolutionestrapideetlediagnostiquesouventfaitàunstadeavancé

Lesaltérationsgéniquessontsévèresetfréquentes

Lachirurgiecurative nepeutconcernerqu’unnombrelimitédepatients

Lesrésistancesspontanéesouacquisesauxchimiothérapiesetàla radiothérapiesontfréquentes

Diagnostictardif/pasdedépistage

Difficultésdetraitement

Histoiredelamaladie:Unemaladieprécocementmétastatique• Lesadénocarcinomesdupancréassontcaractérisésparunelargepropensionàdévelopperdesmétastases(ganglionnaires,hépatiques,péritonéales,etc…)trèsprécocement (souventdèslediagnostic)

• Laplupartdespatientsseprésententdoncavecunemaladielocalementavancéeouunemaladiedéjàmétastatique

• R1dans17-42%descas• Chezlespatientsayanteuunerésectioncurativeletauxderechuteslocalesestde75-85%etderechutesmétastatiquesde80%

• Lestumeursapparemmentlocaliséesdéveloppentdesmétastasesdansundélaisde6-12mois(16%avantlafindelachimiothérapieadjuvante)suggérantlaprésencedèslediagnosticd’unemaladiemétastatiqueocculte

Métastatique Survie 8-12 mois

Localement avancé Survie 12-15 mois

Localisé opérable Survie 15-20 mois

60%

30%

10%

Degréd’extensionetpronosticdescancersdupancréasaudiagnostic

(dont10%‘bordeline’)

Priseenchargedesadénocarcinomesdupancréasnonmétastatiquesaudiagnostic

Chirurgiecarcinologique

semblantpossible

Chirurgiecarcinologiqued’embléedifficile

Chirurgiepremière

Yat’iluneplacepourlestraitementsnéo-adjuvants?

Traitementsnéo-adjuvants

Commentaméliorerlecontrollocaletmétastatique?

Adénocarcinomedupancréaslocalisé

Chimiothérapie adjuvante

Chirurgiesiaméliorationducontrollocaleetabsencedeprogression

métastatique

Opérable

‘Borderline’

Classificationdesadénocarcinomesdupancréasenfonctiondeleurextension

Journal of Cancer Therapy, 2016, 7, 24-40

Opérabled’embléCancerdupancréas

Patientopérabled’emblé

Artériel Portal

Tumeur Tumeur

SMVSMA

SMVSMA

Scanner


Prévalencedeladénutritionparcancer(2005)

Hébuterne etal.Nutr 2006

Opérableradiologiquement,maisphysiquement?

• Grandâge• Anorexie• Pertedepoids• Hypo-albuminémie• Amyotrophie• Anémieinflammatoire• Douleurs• Ictère• Occlusionhaute• Altérationdel’étatgénéral• Syndromedépressif• ThrombosesveineusesetEP• Diabète• Comorbiditésdutabac

Nécessiteuneremiseenconditionphysique

préalableàlachirurgie

Pré-habilitationsystématiquepour

limiterlesrisquesperetpost-opératoires

SMARTH-HAB

Traitementsadjuvantsdel’adénocarcinomedupancréasréséqué


RecommandationsNCCN2016

Peut-onaméliorercesrésultatsparlaréalisationd’untraitementnéo-adjuvant?


BorderlineCancerdupancréas

D2

PAMS

VMS

Adénocarcinomelocalementavancé=pasmétastatiquemaisavecdesréserveschirurgicales

RecommandationsNCCN:cancerdupancréasborderline

Radiothérapie

Radio-chimiothérapie

Chimiothérapie

Obtenirunediminutiondevolumedelatumeurprimitive

Vérifierl’absencedemétastasesàdistance

BUTS MOYENS

Cancerdupancréasborderline

Eviterlestoxicitéspouvantretarderlachirurgie

Chimiothérapiesdescancersdupancréas

• Monothérapie:Gemcitabine

• Doublet:Nab-paclitaxel +gemcitabine

• Triplet:FOLFIRINOX

Phase III Gemcitabine Monotherapy in Advanced Pancreatic Cancer: Study Design

• Primary endpoint: improvement in specific disease-related signs and symptoms (clinical benefit), including pain and KPS

• Secondary endpoint: weight change• Other endpoints: ORR, survival, time to progressive disease

24Burris III HA, et al. J Clin Oncol. 1997;15:2403-2413.

5-FU, 5-fluorouracil; IV, intravenous; KPS, Karnofsky performance status; ORR, overall response rate; qw, weekly; qw ¾, first 3 of 4 weeks; qw 7/8, first 7 of 8 weeks.

25

Gem, gemcitabine, 5-FU, 5-fluorouracil; OS, overall survival.

Phase III Gemcitabine Monotherapy in Advanced Pancreatic Cancer: Overall Survival

Reprinted with permission. © (1997) American Society of Clinical Oncology. All rights reserved. Burris III, HA et al: J Clin Oncol, Vol. 15(6), 1997: 2403-2413.

Burris III HA, et al. J Clin Oncol. 1997;15:2403-2413.

Intent-to-Treat Gem(n = 63)

5-FU(n = 63)

P Value

Clinical benefit, %Time to clinical benefit, median, weeksDuration of clinical benefit, mean,

weeks

23.87

18

4.83

13

0.0022

OS, median, monthsOS rate, %6 months9 months12 months

5.65

462418

4.41

3162

0.0025

PFS rate, %6 months9 months12 months

2299

555

Time to progression, median, months 2.33 0.92 0.0002ORR, %

PRSD

n = 565.439

n = 57019

NS

5-FU, 5-fluorouracil; Gem, gemcitabine; NS, not significant; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; PR, progressive disease; SD, stable disease.

26Burris III HA, et al. J Clin Oncol. 1997;15:2403-2413.

Phase III Gemcitabine Monotherapy in Advanced Pancreatic Cancer: Efficacy Outcomes

Chauffert B, Ann Oncol 2008

Gem

Gem

CRT

CRT

Chemotherapyorchemo-radiotherapy(C-RT)

Huguet F, J Clin Oncol 2007

FrontlineC-RT Chemotherapy then C-RT

Chemo then CRT

Chemo alone

Chemo then CRT

Chemo alone

PACLocally

advanced,M0

N=449 Gem2months

RCT

R2

Gemcitabine+Erlotinib

Gemcitabine

R1

Erlotinib :100mgavecgemzar ;150mgenmono.Maintenujusqu’àprogressionRCT:RT54Gy (6semaines)+Capecitabine 1600mg/m2

Patientswho notprogressed at 4months

F.Huguetetal.,ASCO2014,A4001

N=269

LAP07:ImpactofC-RTonlocalcontrol?

l Nooverall benefits ofRCT(Hammel ASCO2013LBA4003)

à Overall survival (15,2vs 16,4mois,p=0,82)à Profression-freesurvival (12,5vs 11,8:p=0,21)

l Acceptablesafety ofRCT(more nausea grade3-4:5,9%vs0)

Prob

ability

ofLP

FS

100

0 6

50 HR(95%CI):0,78(0,61-1,01)

Log-rank:p=0,055

Timefrom thefirstrandomization (month)

136133

Nbat risk patients

0

Localprogression-freesurvival

3 9 12 15 18 21 24 27 30 33 36 39 42

136133

113117

6176

3545

2130

1221

711

38

17

14

14

14

14

14

CTRCT

N Events LPFS(mois)

CT 136 125 8,4RCT 133 122 9,9



Sitesofaprogression

l Patientsat2nd randomizationl Progression:236/269pts (88%)

à Localprogressiononly:93(39%)à Metastaticprogression(± local):122(52%)à Progressionatunknownsite:21(9%)


Chemo(n=125)

Local Metastatic Unknown

RCT(n=111)

46% 44% 10%

60%32% 8%

p=0.035


Commentaméliorerlecontrollocal?

Doubletoutriplet?

CA19-9, carbohydrate antigen 19-9; CT, computed tomography; HR, hazard ratio; IV, intravenous; KPS, Karnofsky performance status; NCI CTCAE, National Cancer Institute Common Terminology Criteria for Adverse Events; MRI, magnetic resonance imaging; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; qw 3/4, first 3 of 4 weeks; qw 7/8, first 7 of 8 weeks; RECIST, Response Evaluation Criteria In Solid Tumors; ULN, upper limit of normal.

• Primary endpoint– OS

• Secondary endpoints– PFS and ORR by independent

review (RECIST v1.0)• Safety and tolerability

– By NCI CTCAE v3.0

• With 608 events, 90% power to detect OS HR = 0.769 (2-sided α = 0.049)

• Treat until progression or unacceptable toxicity• Spiral CT or MRI scans every 8 weeks• CA19-9 measurements at baseline and every

8 weeks

Von Hoff DD, et al. N Engl J Med. 2013 Oct 16. [Epub ahead of print]. 32

Phase III Gemcitabine + nab-Paclitaxel in Metastatic Pancreatic Cancer: Study Design

a The 75th percentile represents the time point at which 25% of patients were alive.Gem, gemcitabine; HR, hazard ratio; nab-P, nab-paclitaxel; OS, overall survival; pt, patient. Von Hoff DD, et al. N Engl J Med. 2013;369(18):1691-1703. 33

Phase III Gemcitabine + nab-Paclitaxel in Metastatic Pancreatic Cancer: Overall Survival

nab-P + Gem(n = 431)

Gem(n = 430)

HR/RRR (95% CI) P Value

OS, median monthsOS rate, %12 months 24 months

8.5

359

6.7

224

0.72 (0.62 - 0.83) < 0.001

PFS, median monthsPFS rate, %6 months12 months

5.5

4416

3.7

259

0.69 (0.58 - 0.82) < 0.001

ORR by independent review, %ORR by investigator review, %

2329

78

3.19 (2.18 - 4.66)3.81 (2.66 - 5.46)

< 0.001< 0.001

DCR by independent review, % 48 33 1.46 (1.23 - 1.72) < 0.001

TTF, median, months 5.1 3.6 0.70 (0.60 - 0.80) < 0.001

Decrease in CA19-9 level, % nab-P + Gem (n = 379)

Gem(n = 371)

≥ 20% decrease≥ 90% decrease

6131

4414

< 0.001< 0.001

Von Hoff DD, et al. N Engl J Med. 2013;369(18):1691-1703.

CA19-9, carbohydrate antigen 19-9; DCR, disease control ratio; Gem, gemcitabine; HR, hazard ratio; nab-P, nab-paclitaxel; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; RRR, relative risk ratio; TTF, time to treatment failure.

34

Phase III Gemcitabine + nab-Paclitaxel in Metastatic Pancreatic Cancer: Efficacy Outcomes

CA046 (Lopez-Martín): Subgroup Analysis of Outcomes of the MPACT Trial Based on Primary Tumor LocationEfficacy by Primary Tumor Location Summary

Efficacy Parameter nab-P + Gemn = 431

Gem n = 430 HR or RRR P Value

Tumor location: headn (%) 191 (44) 180 (42) —

OS, median, months 9.3 6.5 0.59 < 0.001

PFS, median, months 5.5 3.7 0.53 < 0.001

ORR, % 25.0 5.0 5.03 < 0.001Tumor location: othern (%)a 237 (55) 246 (57) —OS, median, months 8.1 6.9 0.80 0.033PFS, median, months 5.4 3.7 0.74 0.013ORR, % 21.0 9.0 2.36 < 0.001

a n values different from at-risk populations in the previous slides because of differences in the analysis populations.

Gem, gemcitabine; HR, hazard ratio; nab-P, nab-paclitaxel; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; RRR, response rate ratio.Lopez-Martín J, Ma WW, Balcke P, et al. nab®-Paclitaxel plus gemcitabine vs gemcitabine alone for patients with metastatic pancreatic cancer: influence of primary pancreatic tumor location on efficacy and treatment exposure in the MPACT phase III trial. Poster presented at: 16th World Congress on Gastrointestinal Cancer; June 25 - 28, 2014; Barcelona, Spain [abstract P-0029]. 35

Phase II/III FOLFIRINOX in Metastatic Pancreatic Cancer: Study Design

Conroy T, et al. N Engl J Med. 2011;364:1817-1825.

5-FU, 5-fluorouracil; ECOG, Eastern Cooperative Oncology Group; IV, intravenous; OS, overall survival; PFS, progression-free survival; PS, performance status; q2w, every 2 weeks, qw 3/4, first 3 of 4 weeks; qw 7/8, first 7 of 8 weeks.

Phase II§ Primary endpoint: tumor response§ Secondary end point: safetyPhase III• Primary endpoint: OS• Secondary endpoints: PFS, tumor response, safety, quality of life

36

FOLFIRINOX, 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin; Gem, gemcitabine; HR, hazard ratio; OS, overall survival; Pts, patients.

• Subsequent therapy: 80 patients for FOLFIRINOX and 85 for Gem• Median survival was 4.4 months in both groups from the time of secondary therapy

Phase II/III FOLFIRINOX in Metastatic Pancreatic Cancer: Overall Survival

37Conroy T, et al. N Engl J Med. 2011;364:1817-1825.

Intent-to-Treat FOLFIRINOX(n = 171)

Gem(n = 171)

HR (95% CI) P Value

OS, median, monthsOS rate, %6 months12 months 18 months

11.1

75.948.418.6

6.8

57.620.66.0

0.57(0.45 - 0.73)

< 0.001

PFS, median, monthsPFS rate, %6 months12 months18 months

6.4

52.812.13.3

3.3

17.23.50

0.47(0.37 - 0.59)

< 0.001

ORR, % 31.6 9.4 NA < 0.001DCR, % 70.2 50.9 NA < 0.001Response duration,median, months 5.9 3.9 NA 0.57

Conroy T, et al. N Engl J Med. 2011;364:1817-1825.

DCR, disease control rate; FOLFIRINOX, 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin; Gem, gemcitabine; HR, hazard ratio; NA, not available; ORR, overall response rate; OS, overall survival; PFS, progression-free survival.

Phase II/III FOLFIRINOX in Metastatic Pancreatic Cancer: Efficacy Outcomes

38

However, no data in the NEJM paper on the local pancreatic tumor mass control rate

First Author

No. of Pts with

Metastatic Disease

FOLFIRINOX Regimen/Deliverya5Efficacyb Safety

OSmos

PFS mos

ORR%

Select Grade ≥3 AEs,g(%)

Gunturu1 19c Same starting dose used as reported by Conroy et al.5 All pts received pegfilgrastim; Lower median relative dose intensities vs Conroy et al5 for irinotecan (64% vs 81%) and bolus 5-FU (66% vs 82%)

11.2 9.9 47 Neutropenia (11.4),fatigue (5.7), diarrhea, (2.9),febrile neutropenia (2.9)

Lowery2 61d Median starting dose was 80% as reported by Conroy et al5; prophylactic growth factor was given in 84% of pts

12.5 NR 40 Neuropathy (15),myelosuppression (7)

Mahaseth3 28 Omitted bolus 5-FU, included mandatory G-CSF

NRf NRf 21 Fatigue (11), diarrhea (11), neuropathy (4), neutropenia (4)

Vaccaro4 36e Starting dose undefined; 58% received prophylactic G-CSF; FOLFIRINOX dose was reduced to 75% in 23% of cycles

NA 8g 25g Neutropenia (16.6)

Modified FOLFIRINOX in Advanced Pancreatic Cancer: Retrospective Analysis

1. Gunturu KS, et al. Med Oncol. 2013;30:361. 2. Lowery MA, et al. J Poster presented at: ASCO 2012. [abstract 4057]. 3. Mahaseth H, et al. Abstract presented at: ASCO 2012. [abstract e14614]. 4. Vaccaro V, et al. Abstract presented at: ASCO 2012. [abstract e14661]. 5. Conroy T, et al. N Engl J Med. 2011;364:1817-1825.

5-FU, 5-fluorouracil; AE, adverse event; DCR, disease control rate; FOLFIRINOX, 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin; G-CSF, granulocyte colony-stimulating factor; mos, months; NA, not available; NR, not reached; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; pts, patients.

a Modified based on Conroy study regimen; b OS and PFS given as median; outcomes for pts with metastatic disease only unless otherwise indicated; c Of the 35 pts were treated, 19 had metastatic disease and 17 pts were evaluable for efficacy; d Of the 80 pts enrolled, 61 had metastatic disease; e Identified as advanced, inoperable pancreatic cancer; 26 pts had metastatic disease. PFS and ORR apply to all 36 pts; fMedian OS and PFS were NR after median 5.5 months follow-up; g In all treated pts.

39

FirstAuthor

No. of Pts with

Metastatic Disease

FOLFIRINOX Regimen/Deliverya4

Efficacyb Safety

OS mos

PFS mos

ORR %

Select Grade ≥3 AEs,g (%)

Peddi1 38c FOLFIRINOX5 regimen modified in 51% of pts; 22 pts did not receive 5-FU; irinotecan DR required in 22 pts; 67% of pts received G-CSF starting in cycle 1

1 yr OS: 42%

NA 18 Neutropenia (19.7), abdominal pain, (8.2), fatigue (4.9), febrile neutropenia (4.9), diarrhea (3.3)

Ginocchi2 17d No bolus 5-FU and lower dose of irinotecan (150 mg/m2 q2w); modified dose of infusional 5-FU (2800 mg/m2 over 48 hours q2w). 18% pts received G-CSF

14.8 8.4 33 Neutropenia (35.9), neuropathy (5.1), diarrhea (5.5), fatigue (2.6)

Alessandretti3 19e No bolus 5-FU and DR of at least 1 agent at cycle 1. 73% of pts received prophylactic G-CSF . Median DR cycle 1: 23% for oxaliplatin, 25% irinotecan, and 21% 5-FU

NRf NRf 32g Neutropenia (21%), fatigue (15.7%), diarrhea (5.2), febrile neutropenia (15.6%)

Modified FOLFIRINOX in Advanced Pancreatic Cancer: Retrospective Analysis (cont)

1. Peddi PF, et al. JOP. 2012;13:497-501. 2. Ginocchi L, et al. Presented at ESMO 2012. [abstract 714P]. 3. Alessandretti , et al. Abstract presented at : ASCO 2013. [abstract e15176]. 4. Conroy T, et al. N Engl J Med. 2011;364:1817-1825.

5-FU, 5-fluorouracil; DCR, disease control rate; FOLFIRINOX, 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin; G-CSF, granulocyte colony-stimulating factor; mos, months; NA, not available; NR, not reached; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; pt, patients; q2w, every other week.

40


First Author

No. of Pts with

Metastatic Disease

FOLFIRINOX Regimen/Deliverya6

Efficacyb Safety

OS mos

PFSmos

ORR%

Select Grade ≥3 Aes,g (%)

Lorgis1 42 Standard FOLFIRINOX6

9 NA NA

Neutropenia (57), diarrhea (30), neuropathy (25), febrile neutropenia (14)

Metges2 79 FOLFIRINOX regimen undefined; during treatment, 75% of pts had a dose adjustment

10.2 5.7 37 Total (28)

Faris3 26c FOLFIRINOX regimen undefined NA NA 33 Neutropenia (32), febrile neutropenia (16)

Arlen4 ≈ 93d,e FOLFIRINOX regimen undefined 8.4 NA NA NA

Cartwright5 522 FOLFIRINOX regimen undefined 10.2f NA NA NA

Modified FOLFIRINOX in Advanced Pancreatic Cancer: Retrospective Analysis (cont)

1. Lorgis V, et al. Anticancer Res. 2012;32:4125-4130. 2. Metges J-P, et al. Poster presentation at: ASCO 2012. [abstract 248]. 3. Faris JE, et al. Abstract presented at: ASCO 2012. [abstract e14615]. 4. Arlen AG, et al. Abstract presented at: ASCO 2012. [abstract e16536]. 5. Cartwright TH, et al. Poster presented at: ASCO 2013. [abstract 6607]. 6. Conroy T, et al. N Engl J Med. 2011;364:1817-1825.

DCR, disease control rate; FOLFIRINOX, 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin; KPS, Karnofsky performance score; mos, months; NA, not available; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; pts, patients.

41


FOLFIRINOXnéo-adjuvantdanslescancersdupancréasborderlines

KATHLEENK.CHRISTIANSetal.TheOncologist2014;19:266–274

Résumé:Quellechimiothérapiechoisir?

•GemcitabineMonothérapie• Peuutileennéo-adjuvantcomptetenudufaibletauxderéponse(idempourgemcitabine+erlotinib)

•FOLFIRINOX• Untauxdecontrollocaljusqu’à31.6%(18-47%)• Unprofildetolérancequirequièredespatients‘fit’

•Nab-paclitaxel +gemcitabine• Untauxderéponsede21-29%• Unprofiledetoxicitéplusfavorablequelatripletpourdespatientsplusfragiles

• NonrembourséenFrance

Conclusion

• L’objectifd’obteniruneréponseobjectivelocaleencontrôlantlamaladiemétastatiqueetenutilisantuntraitementnéoadjuvantn’estsusceptibledebénéficierqu’àunnombrelimitédepatients

• Lachimiothérapienéo-adjuvante(parFOLFIRINOX– Nabpaclitaxel/gemcitabine)peutêtreutiliséependant4moisavantlachirurgiepourpermettrelasélectiondepatientsrépondeursetégalementidentifierceuxnedéveloppantpasdemétastasesàdistancedurantcettepériode

• Pourlespatientsopérés,untraitementadjuvantpargemcitabinemonothérapieresteleseultraitementactuellementvalidédansl’attentedesrésultatsdeFOLFIRINOXadjuvant

Opérablesouborderline20-25%

100patients 25patientsRéponseàlachimiothérapie

<30%8patients Operable

?

Prof.EricRAYMONDChefdeServiced’OncologieMé[email protected]

0144126363

URGENCE TUMEUR DU PANCREAS

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Le traitement néo-adjuvant du cancer du pancréas borderline ou localement avancé par Eric...

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