Diminishing returns from FOLFIRI/bev

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catstaff
Posts: 140
Joined: Wed Mar 03, 2021 11:37 am

Diminishing returns from FOLFIRI/bev

Postby catstaff » Mon Aug 30, 2021 4:00 pm

The first half of DH's chemo went well with a rapid decline in CEA. The midpoint CT showed significant shrinkage of all mets for which reduction could be determined. He got down to a CEA of 8.6, then missed a cycle due to being hospitalized for a small-bowel obstruction and his CEA rebounded to 10. He's had 5 more cycles since (started the 6th post-hospitalization today) and his CEA went to 11 (no bev that time), then 9.8, 8.0, 7.6, and the latest was 7.3. CT in two weeks to reassess. It seems the forfiri can keep it down but he can't stay on it continuously. He's having fatigue and reduced appetite now. There's been some mention of maintenance chemo. This cancer didn't respond at all to FOLFOX so not sure what good 5FU alone will do, though the bev seems to be doing its part.
D/H Dx 10/2019 RC age 61
Clinical T4bN2M1a (common iliac and para-aortic lymph nodes)
MSS KRAS G12D
CRT 11/19-1/20 FOLFOX 3/20-7/20
Pelvic exenteration w/LAR 8/20
ypT4bN0Mx G3 0/14 nodes LVI not seen PNI-
CEA 10/19:20, 1/20-11/20:1.6, 4.3, 3.4, 2.7, 2/21:9.0 3/21:18,40 4/21:28,19, 5/21:13.3,8.6
PET 3/21 recurrence in distal nodes, L5 vertebra, pelvis
FOLFIRI+bev 3/21-

IsmailMehdi
Posts: 36
Joined: Sun May 02, 2021 5:52 pm

Re: Diminishing returns from FOLFIRI/bev

Postby IsmailMehdi » Tue Aug 31, 2021 9:49 am

Hi catstaff, good to see shrinkage with FOLFIRI. I had a similar thing when i had to postpone my treatment a week, felt like cancer was back on top. I didn't have a scan and my CEA is not representative, but going back on FOLFIRINOX took a few rounds to get things shrinking again. My understanding is that 5-FU is the main ingredient and easier to tolerate, irinotecan is tough.
Few weeks ago, I was put on prednisone for inflammation and that has kicked my appetite in high gear, it also helped with nausea. I actually gained 5 lb in 2 weeks. Maybe you can get DH something that helps with appetite, that should also help with fatigue.
52M DX: RC lower rectum, guessing now 2cm from AV 4/27/2021
T3N0M0 signet ring-cell carcinoma
Tumor size 30mm
Tumor grade: G3
Baseline CEA 1.0
MSI status: MSS pMMR
Started Folfox 5/12/2021
Switched to FOLFIRINOX from session 2. 8 rounds total.
CT+MRI tumor contained shrunk 80%, no spread to other organs.
CRT started xeloda + 28 days Radiation 9/27

catstaff
Posts: 140
Joined: Wed Mar 03, 2021 11:37 am

Re: Diminishing returns from FOLFIRI/bev

Postby catstaff » Tue Aug 31, 2021 10:02 am

Thanks for the input. Steroids were suggested as one option to ease his side effects but they have their own side effects and we were concerned, but it sounds like that may be something to consider seriously, especially if a low dose would suffice. He does get hopped up from the dexamethasone administered with the chemo, and the fatigue and appetite issues set in when it wears off. Dexamethasone also seems to stop the chronic bleeding from his urostomy.

He didn't respond to FOLFOX (at least the primary didn't, and the radiation would have masked any effect on lymph-node mets) so I am not sure what good 5FU would do him. Irenotecan blocks an enzyme necessary to keep DNA from becoming distorted when it unwinds (e.g. for replication) whereas 5FU seems to mostly work on RNA according to a recent study. Oxaliplatin also seems to work mainly along RNA pathways. He is KRAS* (mutant) which may be more resistant to RNA interference. Plus he didn't have bevacizumab with FOLFOX and that also seems to make a difference.

I'm hoping the scan will give a clue about the source of the residual CEA. It is an excellent marker for him, which is in some ways a good thing. We'll also have to see whether the onc wants to continue folfiri cycles or go straight to maintenance after the next one.

It could certainly be worse, it seems to be continuing to suppress it even if he is not getting as good a response as we'd hoped.
D/H Dx 10/2019 RC age 61
Clinical T4bN2M1a (common iliac and para-aortic lymph nodes)
MSS KRAS G12D
CRT 11/19-1/20 FOLFOX 3/20-7/20
Pelvic exenteration w/LAR 8/20
ypT4bN0Mx G3 0/14 nodes LVI not seen PNI-
CEA 10/19:20, 1/20-11/20:1.6, 4.3, 3.4, 2.7, 2/21:9.0 3/21:18,40 4/21:28,19, 5/21:13.3,8.6
PET 3/21 recurrence in distal nodes, L5 vertebra, pelvis
FOLFIRI+bev 3/21-

IsmailMehdi
Posts: 36
Joined: Sun May 02, 2021 5:52 pm

Re: Diminishing returns from FOLFIRI/bev

Postby IsmailMehdi » Tue Aug 31, 2021 1:22 pm

I should have mentioned the dosage, i started on 30mg daily for prednisone and 100mg metoprolol for BP. I also had an ER trip due to the side effects (GERD). I am now tapering off, down to 7.5 mg prednisone daily and 50mg metoprolol. It coincides with my last treatment, so i should be off once chemo is done. Another nasty side effect is the hyperglycemia. I unfortunately seem to be getting the worst side effects from everything. See my Udenyca post!
52M DX: RC lower rectum, guessing now 2cm from AV 4/27/2021
T3N0M0 signet ring-cell carcinoma
Tumor size 30mm
Tumor grade: G3
Baseline CEA 1.0
MSI status: MSS pMMR
Started Folfox 5/12/2021
Switched to FOLFIRINOX from session 2. 8 rounds total.
CT+MRI tumor contained shrunk 80%, no spread to other organs.
CRT started xeloda + 28 days Radiation 9/27


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