Ascites. Peritoneal mets confirmed.

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LMighty
Posts: 98
Joined: Sun Aug 28, 2016 6:16 am
Location: Hong Kong

Ascites. Peritoneal mets confirmed.

Postby LMighty » Wed May 24, 2017 2:49 am

Update of my mom's situation. 3-4 litres of ascites is just confirmed present so Irinotecan and Erbitux officially failed.

Next steps: paracentesis and Keytruda. Our onc ruled out Stivarga and Lonsurf so I guess Keytruda is our last resort.

Exhausting chemo regimens in less than a year. To say we are worried and disappointed is a huge understatement. I try to stay positive knowing quite a few forum members have success on Keytruda.

Never thought this dreaded disease could be this aggressive.
Last edited by LMighty on Wed May 24, 2017 4:18 am, edited 1 time in total.
Supporter to my mom (64 yr); KRAS wild type; MSS

2012: DX Stage I, rectal cancer; resection and colostomy
5/16: DX Stage III, mets found; right groin lymph node and soft tissue
5-6/16: Radiation + Xeloda
7/16: DX Stage IV, pleural effusion; cancer cells found in fluid
7-12/16: Xelox + Avastin X 6
1/17: Clean PET scan, NED
2/17: Pleural effusion; recurrence
4/17: Iri + Erb X 3
5/17: Ascites; Chemo failed
6/17: Keytruda X 1
7/17: TECENTRIQ (atezolizumab) + COTELLIC (cobimetinib)
9/17: At peace

fumaros
Posts: 214
Joined: Sat Jul 02, 2016 10:26 pm
Location: Syracuse, NY
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Re: Ascites. Peritoneal mets confirmed.

Postby fumaros » Wed May 24, 2017 4:13 am

I am sorry, I hope the next treatment works. Keep trying to stay positive, the fight isn't over yet.
Diagnosed 4/8/16, age 29
Colectomy 4/20/16
Stage III, T4bN1 Tumor 7x6.5x2. Muscinous Adenocarcinoma with SRC features
2/16 lymph nodes
CEA 4/14/16 - 16.8
CEA 6/2/16 - 1.9
CEA 6/17/16 - 0.87, 7/16 - 1.33, 12/16 - 1.14, 4/17 - 0.6, 7/17 - 0.5, 10/17 - 0.9
FOLFOX began 6/24/16 - 11/25/16
10 round FOLFOX, 2 round 5-FU & Leucovorin
MRI & CT 8/16 - NED, CT 12/16 - 10/17 - NED

LMighty
Posts: 98
Joined: Sun Aug 28, 2016 6:16 am
Location: Hong Kong

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Wed May 24, 2017 11:57 am

Thank you. Now I am waiting for the MS status confirmation. I am really worried though because MSI-H seems very unlikely, and there is currently no MSS trial available where I live.

MSI-H or not, our onc was really recommending Keytruda...
Supporter to my mom (64 yr); KRAS wild type; MSS

2012: DX Stage I, rectal cancer; resection and colostomy
5/16: DX Stage III, mets found; right groin lymph node and soft tissue
5-6/16: Radiation + Xeloda
7/16: DX Stage IV, pleural effusion; cancer cells found in fluid
7-12/16: Xelox + Avastin X 6
1/17: Clean PET scan, NED
2/17: Pleural effusion; recurrence
4/17: Iri + Erb X 3
5/17: Ascites; Chemo failed
6/17: Keytruda X 1
7/17: TECENTRIQ (atezolizumab) + COTELLIC (cobimetinib)
9/17: At peace

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Maia
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Joined: Fri Aug 24, 2012 8:00 am

Re: Ascites. Peritoneal mets confirmed.

Postby Maia » Wed May 24, 2017 3:30 pm

LMighty wrote:MSI-H or not, our onc was really recommending Keytruda...


That is nice to hear from the doc : )

I tried to reply to your question in this other thread:
viewtopic.php?f=1&t=57995&p=456927#p456927

LMighty
Posts: 98
Joined: Sun Aug 28, 2016 6:16 am
Location: Hong Kong

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Wed May 24, 2017 4:28 pm

Maia wrote:
LMighty wrote:MSI-H or not, our onc was really recommending Keytruda...


That is nice to hear from the doc : )

I tried to reply to your question in this other thread:
viewtopic.php?f=1&t=57995&p=456927#p456927


Thank you so much Maia. That is really helpful.

What our onc said was that Keytruda works "best" for those with MSI-H and there were "some" successful case even for non-MSI-H. At that moment I thought the message was "it's the last resort so let's just try it regardless of stats". Not sure if he would be willing to try or ever considered the combined use of Keytruda + something. Definitely something I will ask him tomorrow.

Thank you, again.
Supporter to my mom (64 yr); KRAS wild type; MSS

2012: DX Stage I, rectal cancer; resection and colostomy
5/16: DX Stage III, mets found; right groin lymph node and soft tissue
5-6/16: Radiation + Xeloda
7/16: DX Stage IV, pleural effusion; cancer cells found in fluid
7-12/16: Xelox + Avastin X 6
1/17: Clean PET scan, NED
2/17: Pleural effusion; recurrence
4/17: Iri + Erb X 3
5/17: Ascites; Chemo failed
6/17: Keytruda X 1
7/17: TECENTRIQ (atezolizumab) + COTELLIC (cobimetinib)
9/17: At peace

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Maia
Posts: 2443
Joined: Fri Aug 24, 2012 8:00 am

Re: Ascites. Peritoneal mets confirmed.

Postby Maia » Wed May 24, 2017 4:37 pm

I'd say trying Keytruda on its own, first, it's a very sensible approach. It might work just well, on its own --I personally know at least one person in that situation, MSS-- and surely will give your mom a break from chemo! I was just mentioning the other options so you know that even Keytruda wouldn't be the last option : )
The most important thing will be your mom quality of life. Hope she improves greatly in this treatment!!!

LMighty
Posts: 98
Joined: Sun Aug 28, 2016 6:16 am
Location: Hong Kong

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Wed May 24, 2017 8:32 pm

Talked to the onc just now. He said ascites implies a more life-threatening outlook, so to control the symptoms ASAP, Keytruda is worth trying, considering it's potential and minor side effects, regardless of the patient's MS status.

He is very willing to use Keytruda along with other drugs if the initial rounds with Keytruda alone do not produce favourable results. Apparently I was not aware that the use of drugs in my country (Hong Kong) is much more liberal...

So as Maia said, Keytruda would not be the last option. I just hope there is enough time left for Keytruda to work its magic.

Thanks again Maia. You have pointed us to the right direction and given us hope.
Supporter to my mom (64 yr); KRAS wild type; MSS

2012: DX Stage I, rectal cancer; resection and colostomy
5/16: DX Stage III, mets found; right groin lymph node and soft tissue
5-6/16: Radiation + Xeloda
7/16: DX Stage IV, pleural effusion; cancer cells found in fluid
7-12/16: Xelox + Avastin X 6
1/17: Clean PET scan, NED
2/17: Pleural effusion; recurrence
4/17: Iri + Erb X 3
5/17: Ascites; Chemo failed
6/17: Keytruda X 1
7/17: TECENTRIQ (atezolizumab) + COTELLIC (cobimetinib)
9/17: At peace

plastikos
Posts: 273
Joined: Wed Jan 14, 2015 6:09 am

Re: Ascites. Peritoneal mets confirmed.

Postby plastikos » Thu May 25, 2017 6:19 am

LMighty wrote:Talked to the onc just now. He said ascites implies a more life-threatening outlook, so to control the symptoms ASAP, Keytruda is worth trying, considering it's potential and minor side effects, regardless of the patient's MS status.

He is very willing to use Keytruda along with other drugs if the initial rounds with Keytruda alone do not produce favourable results. Apparently I was not aware that the use of drugs in my country (Hong Kong) is much more liberal...

So as Maia said, Keytruda would not be the last option. I just hope there is enough time left for Keytruda to work its magic.

Thanks again Maia. You have pointed us to the right direction and given us hope.

I agree. No harm in trying Keytruda at this point regardless of MS status. Hoping for the best for you guys.
Diagnosed St. IV Colon CA @ 37, male, Kras wild type, MSI-high (2014)
11/2014 Right Hemicolectomy + Liver Resection
12/2014 - 6/2015 FOLFOX + Cetuximab
10/2015 - Recurrence liver
Liver resection 10/2015
FOLFIRI 11/2015 - 5/2016
Recurrence liver, nodes 11/2016
Pembrolizumab 12/2016 -> pseudoprogression (?), biliary obstruction -> biliary stenting
Chemo 4x: most mets inactive and smaller on PET-CT
March 2017 - Back on Pembrolizumab
Sept 2017 - SIRT

LMighty
Posts: 98
Joined: Sun Aug 28, 2016 6:16 am
Location: Hong Kong

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Fri Jun 02, 2017 9:00 am

Thank you plastikos!

Update: The MS status test result won't be available until after a week at earliest. After discussing with the onc we decided to go for the first round of Keytruda on Monday anyway. We don't want to wait in fear of significant progression anymore.

Meanwhile we are considering trying this regimeni in the future if my mom's MS status turns out to be MSS:
http://oncologypro.esmo.org/Meeting-Res ... ancer-mCRC
Our onc agrees to evaluate the possibility beforehand. Unfortunately Tecentriq is not officially approved in Hong Kong so our onc needs to specifically order it from the manufacturer and it could take weeks for the drug to be delivered, and it could be more expensive.
Supporter to my mom (64 yr); KRAS wild type; MSS

2012: DX Stage I, rectal cancer; resection and colostomy
5/16: DX Stage III, mets found; right groin lymph node and soft tissue
5-6/16: Radiation + Xeloda
7/16: DX Stage IV, pleural effusion; cancer cells found in fluid
7-12/16: Xelox + Avastin X 6
1/17: Clean PET scan, NED
2/17: Pleural effusion; recurrence
4/17: Iri + Erb X 3
5/17: Ascites; Chemo failed
6/17: Keytruda X 1
7/17: TECENTRIQ (atezolizumab) + COTELLIC (cobimetinib)
9/17: At peace

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Maia
Posts: 2443
Joined: Fri Aug 24, 2012 8:00 am

Re: Ascites. Peritoneal mets confirmed.

Postby Maia » Fri Jun 02, 2017 12:58 pm

LMighty wrote:Update: The MS status test result won't be available until after a week at earliest. After discussing with the onc we decided to go for the first round of Keytruda on Monday anyway. We don't want to wait in fear of significant progression anymore.


That is so proactive from your mom's doc, how great.

Meanwhile we are considering trying this regimeni in the future if my mom's MS status turns out to be MSS:
http://oncologypro.esmo.org/Meeting-Res ... ancer-mCRC

Of course. That regimen has been discussed extensively in different threads in this forum. We have a fellow, ACPdiddy, in that trial viewtopic.php?f=1&t=57849&p=455797
There are other similar trials ongoing. One that adds bevacizumab --Avastin-- to cobimetinib and anti PD-L1, NCT02876224; that is interesting because adds an agent that we know it is active on mCRC. Other trial for MSS NCT02060188 combines cobimetinib + anti PD-1 + anti CTLA4 --Yervoy, an already approved immuno for melanoma.

LMighty: atezolizumab/ Tecentriq is an anti PD-L1. Even if it has a slightly different mechanism of action than an anti PD-1 --as pembrolizumab/Keytruda or nivolumab/Opdivo are--, so far everything points to the fact that they have similar results.
So, the combination of Keytruda with cobimetinib --Cotellic-- or any other MEK inhibitor available in Hong Kong --like trametinib (Mekinist) should be equivalent.

LMighty
Posts: 98
Joined: Sun Aug 28, 2016 6:16 am
Location: Hong Kong

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Fri Jun 02, 2017 8:23 pm

Maia wrote:
LMighty wrote:Update: The MS status test result won't be available until after a week at earliest. After discussing with the onc we decided to go for the first round of Keytruda on Monday anyway. We don't want to wait in fear of significant progression anymore.


That is so proactive from your mom's doc, how great.

Meanwhile we are considering trying this regimeni in the future if my mom's MS status turns out to be MSS:
http://oncologypro.esmo.org/Meeting-Res ... ancer-mCRC

Of course. That regimen has been discussed extensively in different threads in this forum. We have a fellow, ACPdiddy, in that trial viewtopic.php?f=1&t=57849&p=455797
There are other similar trials ongoing. One that adds bevacizumab --Avastin-- to cobimetinib and anti PD-L1, NCT02876224; that is interesting because adds an agent that we know it is active on mCRC. Other trial for MSS NCT02060188 combines cobimetinib + anti PD-1 + anti CTLA4 --Yervoy, an already approved immuno for melanoma.

LMighty: atezolizumab/ Tecentriq is an anti PD-L1. Even if it has a slightly different mechanism of action than an anti PD-1 --as pembrolizumab/Keytruda or nivolumab/Opdivo are--, so far everything points to the fact that they have similar results.
So, the combination of Keytruda with cobimetinib --Cotellic-- or any other MEK inhibitor available in Hong Kong --like trametinib (Mekinist) should be equivalent.


Thank you so much, Maia! Very interesting info. I will definitely talk to our onc about this.
Supporter to my mom (64 yr); KRAS wild type; MSS

2012: DX Stage I, rectal cancer; resection and colostomy
5/16: DX Stage III, mets found; right groin lymph node and soft tissue
5-6/16: Radiation + Xeloda
7/16: DX Stage IV, pleural effusion; cancer cells found in fluid
7-12/16: Xelox + Avastin X 6
1/17: Clean PET scan, NED
2/17: Pleural effusion; recurrence
4/17: Iri + Erb X 3
5/17: Ascites; Chemo failed
6/17: Keytruda X 1
7/17: TECENTRIQ (atezolizumab) + COTELLIC (cobimetinib)
9/17: At peace

LMighty
Posts: 98
Joined: Sun Aug 28, 2016 6:16 am
Location: Hong Kong

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Sun Jun 04, 2017 12:55 pm

Maia wrote:So, the combination of Keytruda with cobimetinib --Cotellic-- or any other MEK inhibitor available in Hong Kong --like trametinib (Mekinist) should be equivalent.


Hi Maia,

One thing -- did you mean even though we can't get Tecentriq in Hong Kong, the combination of Keytruda with Cotellic is thought to produce similar result without Tecentriq?
Supporter to my mom (64 yr); KRAS wild type; MSS

2012: DX Stage I, rectal cancer; resection and colostomy
5/16: DX Stage III, mets found; right groin lymph node and soft tissue
5-6/16: Radiation + Xeloda
7/16: DX Stage IV, pleural effusion; cancer cells found in fluid
7-12/16: Xelox + Avastin X 6
1/17: Clean PET scan, NED
2/17: Pleural effusion; recurrence
4/17: Iri + Erb X 3
5/17: Ascites; Chemo failed
6/17: Keytruda X 1
7/17: TECENTRIQ (atezolizumab) + COTELLIC (cobimetinib)
9/17: At peace

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Maia
Posts: 2443
Joined: Fri Aug 24, 2012 8:00 am

Re: Ascites. Peritoneal mets confirmed.

Postby Maia » Sun Jun 04, 2017 4:21 pm

LMighty wrote:One thing -- did you mean even though we can't get Tecentriq in Hong Kong, the combination of Keytruda with Cotellic is thought to produce similar result without Tecentriq?


Yes. Tecentriq (atezolizumab) is an anti PD-L1. The 'L' in the name PD-1 stands for the Ligand in the tumour cells. Keytruda (pembrolizumab) is an anti PD-1.
PD-1 is on the T cells of the immune system, PD-L1 is on the tumor cells. So both drugs release the breaks of the immune system in a same pathway, but in different 'places'. They are not the same and probably some time from now we'll learn about the particularities but, right now, clinically, all the anti PD-1 and the anti PD -L1 have demonstrated similar results. Some are ahead in the 'race' because the pharmas started testing first one instead of other, or regarding one cancer or other.
You can read a better explanation here, and watch a video --it is about a type of lung cancer, because those drugs have been first tested for that: http://cancergrace.org/lung/2016/04/20/ ... d-1_pd-l1/

There are the approved ones, for different cancers --there are many more in trials, so one always can go to a trial for an equivalent:

Anti PD- 1: Keytruda (pembrolizumab) , Opdivo (nivolumab)

Anti PD- L1: Tecentriq (atezolizumab), Bavencio (avelumab), Imfinzi (durvalumab)
Last edited by Maia on Sun Jun 04, 2017 4:28 pm, edited 2 times in total.

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Maia
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Re: Ascites. Peritoneal mets confirmed.

Postby Maia » Sun Jun 04, 2017 4:25 pm

---
Adding to that:
Also, there are two MEK inhibitors approved, as I said, not only Cotellic --it was just that that particular trial was ran with that one.

MEK inhibitors: Cotellic (cobimetinib), Mekinist (trametinib).

Soon, others will be approved, probably: binimetinib and selumetinib.

SarahS
Posts: 44
Joined: Sat Mar 11, 2017 12:44 pm

Re: Ascites. Peritoneal mets confirmed.

Postby SarahS » Sun Jun 04, 2017 6:04 pm

Sorry to butt in on your post LMighty, and wishing you and your Mom all the best, I went through similar with my mother last year

Quick question for Maia, and thank you so much for all of your incredibly useful information,

As far as you understand, are PD-1 inhibitors better suited towards MSI tumors and PD-L1 likely to work better for MSS or is it as I suspect not that simple ?
Wife and caregiver to husband diagnosed with stage 4 colon cancer Nov 2016
Emergency surgery to remove blockage in cecum 12/03/2016
Stage 4 colon cancer. Mets to liver, peritoneum, possibly lungs
K-Ras mutant MSS
01/05/2017 Begin Folfox 6 plus Avastin
CEA pre surgery 114, post surgery 70, 02/2017- 35 03/2017- 23 04/2017- 12


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