Use of Xeloda and radiation after Whipple Procedure

freeio

In October I was treated at the University of Alabama, Brimingham (UAB) hospital for colangeocarcinoma (a tumor on the common bile duct where it goes through the pancreas). Dr. Vickers did a Whipple procedure, and the chief pathologist inspected the removed parts, and noted that the tumor was categorized as a T1, and while the pancreas was not yet involved, that there was an attack on one of thirteen removed lymph nodes and also on one nerve bundle. They think that they may have gotten it all. However, there is a significant chance that they didn't.

Now that the surgery recovery is mostly done, the plan is to aggressively treat what might remain with a simultaneous combination of radiation and chemo, in this case using Xeloda (capecitabine). In reading the literature, Xeloda is approved for treatment of breast cancer and colon cancer, but nothing else is mentioned.

So my question is this: has anyone else been through a Xeloda treatment for anything similar?

Thanks!

Marty
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

leo · Site Admin Joined: 23 Sep 2004 Posts: 1574

Marty,

Thanks for posting. Even though Xeloda has its use approved for those indications you mentioned, it's been used off-label for a number of other cancers. I searched the literature and came up with 2 abstracts, below:

1: Cancer. 2004 Aug 1;101(3):578-86.

Oral capecitabine for the treatment of hepatocellular carcinoma,
cholangiocarcinoma, and gallbladder carcinoma.

Patt YZ, Hassan MM, Aguayo A, Nooka AK, Lozano RD, Curley SA, Vauthey JN, Ellis
LM, Schnirer II, Wolff RA, Charnsangavej C, Brown TD.

Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA. yzpatt@umm.edu

BACKGROUND: The goal of the current study was to evaluate the efficacy and toxicity of capecitabine in patients with nonresectable hepatobiliary carcinoma.
METHODS: The authors performed a retrospective analysis of all patients with hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), or gallbladder carcinoma (GBC) who were ever treated with oral capecitabine. The medical records of 116 patients with hepatobiliary carcinoma who were treated at The University of Texas M. D. Anderson Cancer Center (Houston, TX) between July 1998 and March 1999 were reviewed. RESULTS: A total of 63 patients were treated with capecitabine (37 with HCC, 18 with CCA, 8 with GBC). Capecitabine 1000 mg/m(2) was administered twice daily for 14 days. Treatment was repeated every 21 days. Each patient received 1-15 treatment cycles. Nine patients (14%)-11% of patients with HCC, 6% of patients with CCA, and 50% of patients with GBC-had either a complete response (CR) or a partial response. A CR was radiologically confirmed in one patient with HCC and in two patients with GBC. The median survival times were 10.1 months (95% confidence interval [CI], 4.5-15.7 months) for patients with HCC, 8.1 months (95% CI, 7.4-8.9 months) for patients with CCA, and 9.9 months (95% CI, 4.4-15.4 months) for patients with GBC. The most common toxicity was hand-foot syndrome (37%). Grade 3 thrombocytopenia occurred in 8% of patients with HCC. No other significant toxicities were observed. For all patients, response to treatment was positively correlated with survival and decline in tumor markers. CONCLUSIONS: Capecitabine was found to be safe for patients with hepatobiliary carcinoma, including those with cirrhosis. The antitumor activity of single-agent capecitabine was most pronounced in patients with GBC, was modest in patients with HCC, and was poor in patients with CCA.

PMID: 15274071 [PubMed - indexed for MEDLINE]

2: Onkologie. 2002 Apr;25(2):182-4.

Capecitabine as second-line treatment for metastatic cholangiocarcinoma: a report of two cases.

Stemmler J, Heinemann V, Schalhorn A.

Abteilung fur Innere Medizin III, Universitatsklinik Munchen, Germany.
joachim.stemmler@med3.med.uni-muenchen.de

BACKGROUND: The management of recurrent, metastatic cholangiocarcinoma still remains a problem since this tumor entity is classified as
chemotherapy-resistant. When advanced or metastatic disease is diagnosed, the therapeutic efforts are essentially directed toward palliation. PATIENTS AND
METHODS: We report on 2 patients suffering from metastatic cholangiocarcinoma.
Both had received previous chemotherapy for metastatic disease, including hepatic artery infusion [5-fluorouracil (5-FU) / folinic acid (FA) and oxaliplatin] and a combination therapy consisting of 5-FU/FA and gemcitabine.
Since a progression of the disease was diagnosed, both patients were started on oral capecitabine at a daily dose of 2,500 mg/m(2) in 2 divided doses for 2 weeks, followed by 1 week rest. RESULTS: Capecitabine was tolerated well and severe side effects were not observed. A stop of progression, documented by imaging procedures and tumor marker kinetics, was achieved in both patients.
CONCLUSION: Capecitabine could potentially be used for secondline treatment in patients with progressive metastatic cholangiocarcinoma. Copyright 2002 S.
Karger GmbH, Freiburg

Publication Types:
Case Reports

PMID: 12006771 [PubMed - indexed for MEDLINE]
_________________
Leonardo F - Webmaster Cancer Forums
Disclaimer: this information is for informational purposes only. It is not medical advice.

freeio · Posted: Wed Dec 22, 2004 10:29 pm Post subject: Interesting abstracts

Thanks, Leo!

Each case is different, I suppose. Since I am dealing with CCA, that first abstract is not terribly positive, but then again, single studies are interesting but do not prove a lot.

By the way, I was told by Dr. Susan Russo (radiation oncologist) that I am as blessed as one could be in that the CCA was caught so early (T1 tumor, basically self contained in the bile duct, and no evidence of pancreatic involvement - yet) that there were no statistics for survival/remission for my group. It would seem that CCA is seldom caught until at least stage 3. The Whipple procedure removed all of that and a lot more, so there is hope that they got it all, except for the inevitable microscopic particles that no one can be sure of.

So radiation and treatment with Xeloda (1650 mg, twice a day) begins on Tuesday December 28th, all at once. I will be interested to see just how this goes. I'll report back once I know more.

Thanks again,

DM
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

freeio · Posted: Tue Mar 22, 2005 9:51 pm Post subject: So far, so good...

I thought it a good time to report back. The six weeks, five days a week, of radiation (250MEV photons from a Varian Cliniac 2100) with Xeloda every weekday was exhausting, but the chemo symptoms were not as bad as any of the literature suggested. The predicted hand and foot degeneration only showed up during the last week of treatment, and healed up as would blisters - i.e. split open, peeled, and healed from underneath, during the following month off treatment.

There appeared to be no side effects from the radiation treatment itself, beyond the usual loss of hair where they aimed the radiation generator, i.e. on the stomach, sides, and back, where the radiation hit. The machine is rather loud, but I didn't feel a thing while it ran.

The second round of Xeloda by itself (14 days straight) is over, and other than exhaustion, there were no visible side effects. I didn't eat as much, not because anything tasted wrong, but rather because I was too tired to care about food.

Monday I went back to The Kirklin Clinic (University of Alabama Brimingham Hospital's fabulous facility) for follow up tests, and the CT scan and blood work came out clean. Dr. James Posey stated that they could find no sign of cancer activity. I am scheduled for another round of chemo using Xeloda, and then don't have to go back for another scan and bloodwork until I see both Dr. Posey (the oncologist) and Dr. Selwyn Vickers (the surgeon) until July.

So far, so good. I am very thankful!
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

Lori · New User Joined: 23 Mar 2005 Posts: 1 Location: Pa

Hello,
New here.
Glad to hear you're doing good!
My dad was just diagnosed w/ cholangiocarcinoma, and I'm just terrified. I'm doing as much research as possible, but I have to get more specific information from his doctor.
I was wondering if you did anything else to help with this- diet? vitamins? I'm looking for things to take back to his doctor so we can work with him on this.

Blessings to all-
Lori

freeio · Posted: Wed Mar 23, 2005 8:38 am Post subject: I don't know if this helps...

I cannot speak for anyone else on this matter, but my case the treatment progressed so quickly that there was not much time for anything dietary except for making sure I had a few weeks of protein and vitamin supplements in preparation for the surgery.

The first treatment was an ERCP, where they put this instrument down my throat, through the stomach, and into the small intestine, and then worked their way somehow into the common bile duct where they popped it open and placed a stent to keep it open, so that the bile would stop backing up. They did biopsy work from there, and found nothing cancerous at that time, although Dr. Wilson stated that he had never seen one of these that was not cancerous.

The next treatment was with an ultrasound ERCP, inserted the same way, where they did further investigation, took more biopsy samples, and found nothing cancerous.

The third treatment was the Whipple procedure, where they removed the gall bladder, the head of the pancreas, about a foot of small intestine, part of the stomach, and every lymph node they could reach. When the pathologist looked at what was removed, he found that the tumor was cancerous, and that it was just beginning to spread, but that they thought they got it all out with the Whipple procedure.

I have a friend who also was treated for cholangeocarcinoma, and she had an easier case. They were able to determine that it was benign, and removed it through endoscopic surgery. So not all cases are as complicated as mine.

My advice is to seek treatment quickly. I have been told that this can be an extremely aggressive form of cancer, and that left untreated it can develop into pancreatic cancer very quickly. There are several wonderful cancer treatment centers available to you. Get a referral and go.
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

freeio · Posted: Tue Jul 19, 2005 11:50 am Post subject: Yes there is life after cancer

Yesterday was the big day: Once again we headed down to the Kirklin Clinic in Birmingham, Alabama, for the post cancer checkup. First there were the blood tests, then the ct scan with contrast, then the two visits with Dr. Vickers and Dr. Posey. The verdict was that they see no sign of cancer now, and I don't have to go back until January. This is very good indeed.

After the Whipple procedure October 21, 2004, after the combined radiation and chemo during December, January, and February, and after the rounds of chemo (1650 mg twice a day of Xeloda - Ugh!) which ended in May, life is returning to normal, and I am feeling again like I did before this whole medical event.

Last week I had a routine visit with the family GP who did the initial diagnosis, and he basically said that when I came in presenting painless jaundice, his initial thought was that I had three months left to live. All of the paperwork still says pancreatic cancer, which is called a silent killer for very good reasons. Yet because of great treatment, performed early enough, I am still here and normal life is returning.

There is a moral to this: if the doctor suspects cancer, get a referral to the best cancer center available. Just do it, and do it right away. Please do not put it off.
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

blondie1 · New User Joined: 09 Jan 2006 Posts: 2

Marty - I've just read through your postings and am thankful for what you have shared. My Mother had the exact same case as you, down to the procedures and findings. 1 lymph node affeced out of 13. She has had a rough time recovering from the surgery and was back in the hospital numerous times with nausea and vomiting. She has finally recovered enough that they are about to start chemo and radiation. I'm fearful for how she may respond. How have you been doing since your last posting?

freeio

Life is good. I am getting some energy back after being extremely tired ever since completing the treatments. There is continuing gastric distress, and at the beginning of December they perfrmed an EGD (esophogastroduodenoscopy - i.e. they used a fiberoptic snake down my throat to take a look) and found that I have developed intestinal ulcers. Apparently after the Whipple procedure there is no valving for bile or stomach acid, and so the upper small intestines get a contrant flow of that. That explains the continued pain. They are treating that with protonics, which basically eliminates the production of stomach acid, which has its own side-effects. I cannot take that indefinitely, either, since protonics is carcinogenic over the long term.

There is one other side-effect which bears mentioning. After the radiation and chemotherapy, there is a depression of the immune system, and there have been recurring bouts with skin fungus (tinea corporis). The body simply does not work the way it used to. So beware of all infections and get them dealt with immediately.

But on the other hand I am able to commute an hour each way to/from an engineering job, and am still around to talk about it. I can sing in the church choir, teach Sunday school, do remodelling at home - I cannot do as much at a time, but it all is doable. So there is life after cholangiocarcinoma, surgery, radiation treatment, and chemotherapy, although life is a bit different than it was.

Marty
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

blondie1 · New User Joined: 09 Jan 2006 Posts: 2

Marty -
I'm glad to hear that you are still doing well, despite a few set backs. My Mom went back into the hospital on Friday the 13th with a high fever. Turns out she had an infection in her port. They removed it and put her on antibiotics and she is well again. Her Oncologist told her that he can't start chemo and radiation until she has no signs of infection so he wants to wait another 3 weeks. She had the original surgery in September, so it has been a long time with no follow up treatment. Her Oncologist has also left the option out there for not doing treatment. She is 72 and I'm sure he feels like she may live a better quality of life, albeit shorter, without it. She is opting for chemo and radiation. She has been a major inspiration to all of us.

catalina

Thats great news Marty

My husband was suppose to have a whipple Oct 22, 2005. But the interns
forgot to take him off his blood thinners, they also forgot to ask the heart Dr. if he could come off them. He couldn't come off them without throwing blood clots, so they sent him to have chemo for four months till he could
be taken off the thinners. The chemo Dr. did a full body scan, it show the cancer in his lungs and liver he told us no whipple. I ask him if it had spread that much in two weeks, he said it was their policy to do a full scan before any treatment, that all I got out of him. He went to Kirklin and Dr Vickers.

Catalina

freeio · Posted: Fri Feb 24, 2006 9:20 am Post subject: Another progress report

My six month checkup was a good one - Dr. Vickers and Dr. Posey said nothing has changed, and that I do not have to come back for six months. That is a good thing, since with the blood work and CT scans, each checkup costs about $3600.

There is however continued gastric distress. This has become the new "normal" condition. I finally figured out that I could reduce the pain level by avoiding coffe, tea, and all carbonated beverages. That was nowhere suggested by any of the doctors, but it does make sense, especially since the diet soda products tend to be acidic. Dr. Wilson already put me on Protonix to reduce the production of stomach acid, in order to see if the intestinal ulcers will heal.

The energy level is sufficient to get back to remodelling the kitchen - a project which was delayed a year and a half by the cancer incident. So I am alive and happy about it. The little problems I can deal with.

Cheers!
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

freeio · Posted: Tue Apr 11, 2006 1:26 pm Post subject: Next issue: pancreatitis

During February, I developed some new symptoms, including constant abdominal and back pain, which became much worse after eating. Dr. Vickers diagnosed the problem as pancreatitis, involving what was left of the pancreas after the Whipple Procedure. At UAB Hospital, Dr. Wilcox removed a stent which had been inserted into the pancreatic duct, which seemed to be irritating the pancreas. That involved eight days of hospitalization, as first there were lots of tests, and then it took two trys using an ERCP to grab onto the stent and pull it out. The stent they removed looks like a piece of 100 pound test fishing line, about three inches long. It apparently is hollow. One end looked like fresh plastic, and the other end looked like it had been chemically attacked.

The pain is somewhat lower now, but pancreatitis does not just go away quickly. This is apparenty just one more thing to look out for after a Whipple Procedure surgery.
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

scodaman · New User Joined: 23 Apr 2006 Posts: 5

This is the first time I have looked at this site and at last I have found someone alive+kicking after a whipples.I presented in 1998 with obstructive jaundice+was thought after various investigations to have a cholangiocarcinoma.I had my whipples in August that year--the histology report came back as a gallstone!!What is done is done and you have to get on with it-lucky I suppose it was benign so no further treatment needed.However everything has some side effects.my main problem is reflux+regurgitation for which I take nexium40mgs a day+cholistyramine 1 sachet a day-I also have chronic anaemia and b12 deficiency.i lead quite a normal life +work part-time so there is life after whipples.I do have raised liver enzymes but that could be drug related.Would love to hear from anyone in the same or a similar position.

freeio · Posted: Mon Apr 24, 2006 8:57 am Post subject: More painb, more tests

The past month or two have been ones of increasing pain. Even after the pancreatic duct stent was removed, there was only momentary relief, and now it is as painful as ever. So now they have decided to look a bit farther and see what else may have gone wrong.

On Tuesday April 25, 2006, I am scheduled for a combined PET/CT scan at Kriklin Clinic in Birmingham, Alabama. Unlike what was done at the beginning of April, this is a much more wide-ranging test, and should be able to localize anything which has an unusual metabolic rate, such as tumors.

The PET/CT scan is an expensive test, and required pre-approval from Blue-Cross Blue-Shield of Alabama, and that was a strange process. It turns out that they have outsourced such approvals to an outfit in New York, which only seems to communicate by snail mail. So ten days were lost to an intentionally slow process. At this pain level, I am singularly unimpressed.

I have one more thought. While I was hospitalized at UAB Hospital at the beginning of April, a good friend was on the same floor, after the same diagnosis and surgery. She had been there for seven weeks continuously with one complication after another, and while I was there, she died. Of the four people I know who have had this in the last three years, I am the only one left alive. I fully intend to stay that way, although the statistics do not seem terribly encouraging.

Cheers!

Marty
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

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