Ascites. Peritoneal mets confirmed.

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chrissyrice
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Location: Atlanta, Georgia

Re: Ascites. Peritoneal mets confirmed.

Postby chrissyrice » Sun Jun 04, 2017 6:39 pm

Following ...

I am hoping for the best for your mom and so glad you have a good oncologist working with you and your mom.

I have a few friends that I know might benefit from this post and I actually understand the detail of information too. While I may not be in the same situation right now... the data and results seems to at least give another option.

I know Maia from the other boards I follow as well and she is so amazing!! (right Maia :lol: )

Chrissy
Dx 10-31-09 Surgery 12-1-09 Sigmoid Colon Stage IIIb; Chemo Feb 2010-Aug 2010; 4 rounds Folfox; 8 rounds 5FU & Leucovorin;12-16-2010 PET/CT Scan Cancer Free;7-05-2012 CT Scan NED 2 years;10-13-2013 NED 3 yrs; 08-01-2014 NED 4 yrs; 06-30-2015 Stage 4 iliac lymph node(s) 08-11-2015 Surgery 3 cm tumor and iliac artery graft done. Positive margins in the abdominal aorta, No chemo. 03-16-2016 CT Scan Stable,06-16-2016 CT Scan Stable,09-21-2016 CT Scan Stable,12-2016 Stable,03-31-17 Stable,
Recurrence 6-30-17

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

Re: Ascites. Peritoneal mets confirmed.

Postby Maia » Sun Jun 04, 2017 7:34 pm

SarahS wrote: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 ?


No, there are not data at all supporting the idea that one of both would work better in MSI or MSS. What do we know, right now, is that checkpoint inhibitors of the pathway PD-1 / PD1-L 1 --ALL of them-- many times work well for MSI-High *as monotherapy*. Meaning: you are MSI- high --also called MMR deficient--- and you have high possibilities of having a great response to just one of these drugs. One of them has been approved for MSI-high CRC, the others not at the present day --but they are approved for other cancers--, but it is just a matter of time, probably, until all of them are approved for MSI-high CRC.

For those who are MSS --also called MMR proeficient---, it is very unlikely that a checkpoint inhibitor anti PD-1 or anti PD-L1 will work, on its own, as monotherapy. So far, the responses are starting to be seen with COMBINATIONS: with chemotherapies, with monoclonal antibodies, with targeted agents, with other immunotherapies. The only 'monotherapy' for which we know a response ---complete response, I have to add-- is an immunotherapy: adoptive T-cell therapy --the TIL trialat NIH, that our friend Celine underwent.

Eh, Chris, you're too kind. : )
Last edited by Maia on Sun Jun 04, 2017 7:39 pm, edited 1 time in total.

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

Re: Ascites. Peritoneal mets confirmed.

Postby SarahS » Sun Jun 04, 2017 8:13 pm

Thank you so much Maia .
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

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

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Mon Jun 05, 2017 7:07 am

Maia wrote:
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)


Thank you so much Maia. Mentioned your suggestion to our onc today and he agreed that we may try Keytruda + Cotellic. He will come up with the right regimen for the next infusion, depending on the MS status test result.

First infusion went well and I hope Keytruda does its magic ASAP. Fluids reaccumulate in my mom's lungs and peritoneum but the amount is not enough for safe tapping and they affect my mom's appetite and breathing.
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
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Location: Hong Kong

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Mon Jun 05, 2017 7:15 am

SarahS wrote: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

chrissyrice wrote:I am hoping for the best for your mom and so glad you have a good oncologist working with you and your mom.


Thank you SarahS and chrissyrice! Wish you all the best in your fight.
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 » Mon Jun 05, 2017 7:18 am

Every good thought heading you mom's way, LMighty. She's being a trailblazer!
May the immunotherapy be of help with the pleural effusions, may it relief her symptoms soon!

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chrissyrice
Posts: 1151
Joined: Thu Sep 23, 2010 8:44 am
Location: Atlanta, Georgia

Re: Ascites. Peritoneal mets confirmed.

Postby chrissyrice » Mon Jun 05, 2017 5:07 pm

I will keep praying for your mom... yes she is a *Trail Blazer* and let her know that she is truly blessed to have you and a good doctor too.

Chrissy
Dx 10-31-09 Surgery 12-1-09 Sigmoid Colon Stage IIIb; Chemo Feb 2010-Aug 2010; 4 rounds Folfox; 8 rounds 5FU & Leucovorin;12-16-2010 PET/CT Scan Cancer Free;7-05-2012 CT Scan NED 2 years;10-13-2013 NED 3 yrs; 08-01-2014 NED 4 yrs; 06-30-2015 Stage 4 iliac lymph node(s) 08-11-2015 Surgery 3 cm tumor and iliac artery graft done. Positive margins in the abdominal aorta, No chemo. 03-16-2016 CT Scan Stable,06-16-2016 CT Scan Stable,09-21-2016 CT Scan Stable,12-2016 Stable,03-31-17 Stable,
Recurrence 6-30-17

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

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Tue Jun 06, 2017 7:33 am

Update: it's day 2 since first Keytruda infusion and my mom is hospitalised again due to shortness of breath. Chest X-ray shows slight increase of pleural fluid and a bit more shadowy areas than a few days ago. Our onc says not to worry as it's likely pseudoprogression considering my mom also developed a mild fever, meaning Keytruda may already be working. My mom may need to stay in hospital for a few more days in case her fever got worse in the case of more severe inflammatory response.
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 » Tue Jun 06, 2017 3:22 pm

Sending strong thoughts, my best wishes for this to be a sign that the treatment is working!! xoxo

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

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Sun Jun 11, 2017 9:33 pm

Update: Mom is just hospitalized again for ascites tapping. 4th time in about a month's time so my mom is quite frustrated. Ascites seems to accumulate much faster than before. Again it could be pseudoprogression but there is no way for our onc to tell exactly. Anyways it's way too early to say Keytruda is not working.

MS status result still pending :( :( :(

Besides, our onc checked with Roche. He is not able to order Cotellic and Tecentriq from them as they are not FDA approved for rectal cancer. He is looking into the possibility of off-label use but apparently it's a sensitive issue and he is reluctant unless he can be sure it is not illegal...

So all in all a few minor setbacks but we keep our fingers crossed and hope Keytruda kicks in ASAP
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 » Mon Jun 12, 2017 11:23 am

LMighty, so sorry about the need of repeated tapping for the ascites. I imagine your mom's frustration.
Too early to say about Keytruda's effects so let's just keep hoping for the best.

About Tecentriq, as I've said, maybe it is not worth the hassle, since she's getting Keytruda --an anti PD-1--, which is think to work equivalently to Tecentriq --and anti PD-L1.
Her onc is using already Keytruda off label, I have to say. IF he would think a combination of it with a MEK inhibitor is worth the try --trying to reproduce that trial we discussed previously--, other MEK inhibitor than Cotellic might work equally --as Mekinist, for example, if that one is approved in Hong Kong. But in any case it will be *always* off label, since it's not approved for CRC.

About ascites, I wanted to mention this, in case her onc has some knowledge/ connections about it. In Europe, since 2009 there is an approved intraperitoneal immunotherapy against peritoneal ascites: Catumaxomab, Removab. Removab has been used from the start at the Charité Hospital in Berlin. It is a bispecific (anti-EpCAM x anti-CD3) trifunctional antibody. There have been many trials that led to its approval.
https://www.karger.com/Article/Abstract/324667

Scroll down until 'Publications' to see a list of scientific literature about it: https://clinicaltrials.gov/ct2/show/NCT ... mab&rank=6

I'm mention this because I see it has been studied in HONG KONG. Maybe some of the authors of this article has some information for your mom's onc, about if it is available, somehow, there:

Modern Chemotherapy
Vol.03 No.02(2014), Article ID:52919,8 pages
10.4236/mc.2014.32003

Intraperitoneal Chemotherapy for Gastric Cancer with Peritoneal Carcinomatosis: Is HIPEC the Only Answer?

Ka-On Lam1*, Betty Tsz-Ting Law2, Simon Ying-Kit Law2, Dora Lai-Wan Kwong1
1Department of Clinical Oncology, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
2Department of Surgery, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China

Email: *lamkaon@hku.hk
http://file.scirp.org/Html/1-2510021_52919.htm

Also, PIPAC viewtopic.php?f=1&t=56641 is now available in Singapore: http://medicine.nus.edu.sg/medsur/pipac.html as clinical trial https://clinicaltrials.gov/ct2/show/NCT03172416

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

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Mon Jun 12, 2017 11:55 am

Maia wrote:LMighty, so sorry about the need of repeated tapping for the ascites. I imagine your mom's frustration.
Too early to say about Keytruda's effects so let's just keep hoping for the best.

About Tecentriq, as I've said, maybe it is not worth the hassle, since she's getting Keytruda --an anti PD-1--, which is think to work equivalently to Tecentriq --and anti PD-L1.
Her onc is using already Keytruda off label, I have to say. IF he would think a combination of it with a MEK inhibitor is worth the try --trying to reproduce that trial we discussed previously--, other MEK inhibitor than Cotellic might work equally --as Mekinist, for example, if that one is approved in Hong Kong. But in any case it will be *always* off label, since it's not approved for CRC.

About ascites, I wanted to mention this, in case her onc has some knowledge/ connections about it. In Europe, since 2009 there is an approved intraperitoneal immunotherapy against peritoneal ascites: Catumaxomab, Removab. Removab has been used from the start at the Charité Hospital in Berlin. It is a bispecific (anti-EpCAM x anti-CD3) trifunctional antibody. There have been many trials that led to its approval.
https://www.karger.com/Article/Abstract/324667

Scroll down until 'Publications' to see a list of scientific literature about it: https://clinicaltrials.gov/ct2/show/NCT ... mab&rank=6

I'm mention this because I see it has been studied in HONG KONG. Maybe some of the authors of this article has some information for your mom's onc, about if it is available, somehow, there:

Modern Chemotherapy
Vol.03 No.02(2014), Article ID:52919,8 pages
10.4236/mc.2014.32003

Intraperitoneal Chemotherapy for Gastric Cancer with Peritoneal Carcinomatosis: Is HIPEC the Only Answer?

Ka-On Lam1*, Betty Tsz-Ting Law2, Simon Ying-Kit Law2, Dora Lai-Wan Kwong1
1Department of Clinical Oncology, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
2Department of Surgery, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China

Email: *lamkaon@hku.hk
http://file.scirp.org/Html/1-2510021_52919.htm

Also, PIPAC viewtopic.php?f=1&t=56641 is now available in Singapore: http://medicine.nus.edu.sg/medsur/pipac.html as clinical trial https://clinicaltrials.gov/ct2/show/NCT03172416


Thank you so much Maia! I also thought that maybe we are already using Keytruda after talking to our onc today. Will surely talk to him about this and the possibility of using an approved MEK inhibitor.
He did mentioned he heard of certain ways -- illegal ones -- to get Tecentriq and Cotellic, which also have the risk of being fake. He is looking into more channels so let's hope he comes up with something soon...

Few hours ago I was also researching on Catumaxomab and Removab. Such a conicidence!
I already discussed about intraperitoneal therapy with our onc but he thought it would be too invasive for my mom. Will mention Catumaxomab and Removab to see how he thinks anyway.

Just now I also come across a trial by Novartis that is recruiting in Hong Kong: https://clinicaltrials.gov/ct2/show/record/NCT02460224
Not sure if it is promising as the drugs seem to be similar to Keytruda/Opdivo but worth discussing with our onc.

Failing immunotherapy would mean moving on to Regorafanib and TAS-118 which from our onc's experience have poor results and severe side effects. We are very inclined to stop all treatment if it came to that, so our onc is on the same page with us that we do everything possbile to get immunotherapy working. :x

Maia, as always, thank you so very much for your advice and insights!
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

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

Re: Ascites. Peritoneal mets confirmed.

Postby Maia » Mon Jun 12, 2017 12:25 pm

LMighty wrote:
Just now I also come across a trial by Novartis that is recruiting in Hong Kong: https://clinicaltrials.gov/ct2/show/record/NCT02460224
Not sure if it is promising as the drugs seem to be similar to Keytruda/Opdivo but worth discussing with our onc.


But of course! You have TWO aplicable trials in Hong Kong. If you put 'Hong Kong' in the Location field in the clinical trial finder for MSS-CRC in my signature, you will get them.
One of those is the one you mention --a anti LAG3 plus anti PD-1. A Keytruda equivalent, but combined with other drug --which is needed for this to work, if she's MSS.
The other is... atezo + cobi. https://clinicaltrials.gov/ct2/show/study/NCT02788279 But it looks like all the Hong Kong sites are full. And your mom could had get in the monotherapy arms, or the rego arm. I thought your mom's onc checked, and that's why he was looking at it off label.

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

Re: Ascites. Peritoneal mets confirmed.

Postby LMighty » Mon Jun 12, 2017 11:21 pm

Had an interesting discussion with our onc just now.

Bad news first -- test result is out and my mom's MS status is indeterminate. According to our onc, MS status is determined by comparing "normal cells" to "malignant cells" in the sample. Biopsy would yield most accurate result but there is no accessible site for it in my mom's case, so only the pleural fluid and ascites were tested. There were not enough "normal cells" to be compared with "malignant cells" in the fluids. Now they are gong to test the tissue taken from the resection years ago. Our onc said although that is not recent sample, result is likely to still be accurate. So we wait for another 2 weeks for results...

Our onc has also been closely contacting the persons-in-charge from the manufacturers to at least get a MEK inhibitor for when my mom turns out to be MSS. (He even showed his whatsapp conversation with the persons-in-charge to me to put my mind at ease!)

About intraperitoneal therapy, he considers it having limited benefit as the disease is "flowing through the whole body". He would rather try Avastin if the goal is to slow down BOTH pleural fluid and ascites accumulation. To truly treat the ascites, we need to wait for Keytruda to hopefully work.

He is quite interested in the Novartis clincial trial. He said he has very close relationship with Novartis and agreed to look into the trial.

So we did make a bit of progress, thanks to all the useful information and encouragement on this amazing forum! English is not my native language so I may sound weird at times but I am forever grateful!
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 25, 2017 10:31 pm

Bad news. MS status finally confirmed. My mom is MSS so the only option left for her is combining Keytruda with Cotellic and Tecentriq--if we can get them, that is. Our onc is working on that. Most likely he can only get Cotellic though.

Anyhow, we are not giving up.
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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