Durable Response and Good Tolerance to the Triple Combination of Toripalimab, Gemcitabine, and Nab-Paclitaxel in a Patient With Metastatic Pancreatic Ductal Adenocarcinoma

Lin Shui, Ke Cheng, Xiaofen Li, Pixian Shui, Shuangshuang Li, Yang Peng, Jian Li, Fengzhu Guo, Cheng Yi, Dan Cao, Lin Shui, Ke Cheng, Xiaofen Li, Pixian Shui, Shuangshuang Li, Yang Peng, Jian Li, Fengzhu Guo, Cheng Yi, Dan Cao

Abstract

Background: The performance of immune checkpoint inhibitor (ICI) monotherapy was proved to be disappointing in pancreatic ductal adenocarcinoma (PDAC). Increasing evidence has shown the promising efficacy of ICIs combined with systemic therapy in the first-line treatment in solid tumors. Case presentation: We reported a case of a metastatic PDAC patient who had a long-term partial response and good tolerance to the combined approach of toripalimab (a novel PD-1 inhibitor) and gemcitabine plus nab-paclitaxel (GA). PD-L1 positive expression was detected in his liver metastases. Besides, we described a phenomenon of pseudo-progression of this patient during the course of therapy. Conclusion: As the first-line treatment of metastatic PDAC patients, GA plus toripalimab may provide a novel combined approach with favorable response and manageable toxicity. Further clinical trials are needed to confirm the results. Pseudo-progression requires special attention and to be differentiated with true progression in patients undergoing immunotherapy.

Keywords: PD-1 inhibitor; case report; chemotherapy; combination therapy; durable response; good tolerance; metastatic pancreatic ductal adenocarcinoma.

Copyright © 2020 Shui, Cheng, Li, Shui, Li, Peng, Li, Guo, Yi and Cao.

Figures

Figure 1
Figure 1
The histopathology and immunohistochemistry (IHC) of metastatic tumor tissues of this patient. (A) The H&E staining in the microscopic observation (100×). (B) Immunohistochemical staining for PD-L1 expression (400×) showed that the tumor cells were positive for PD-L1. (C) The positive control of the IHC of PD-L1 expression (200×). (D) The negative control of the IHC of PD-L1 expression (200×).
Figure 2
Figure 2
Response evaluation during the clinical course. (A) Trends in the level of tumor markers, including CA 199, CA 125 (left Y-axis), and CEA (right Y-axis) corresponding to the treatment timeline. X-axis showing the date of the disease course. The loss of the first value of CA 199 was due to the out of range of detection. (B) Representative images of the CT scan showed that both primary and metastatic lesions were shrunk and decreased after two cycles of gemcitabine plus nab-paclitaxel combined with a PD-1 antibody (toripalimab). Red circles indicate the primary pancreatic lesions.
Figure 3
Figure 3
Pseudo-progression of liver metastases after four cycles of toripalimab combined with gemcitabine and nab-paclitaxel, which was confirmed by favorable outcomes at the next assessment of six cycles. Red arrows indicate the appearance of new lesions that were invisible at previous CT evaluation and then disappeared after the continuation of therapy.

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