Oxaliplatin or irinotecan-based re-challenge should be considered as a third or fourth line treatment option in select patients with mCRC. CBR and especially TTP compare favorably to approved third line therapies such as regorafenib or trifluridine-tipiracil.

Introduction Patients with active cancer have a high risk for venous thromboembolism (VTE). The current treatment of choice for cancer-associated thrombosis is low molecular weight heparin (LMWH). Evidence for the efficacy and safety of the target-specific oral anticoagulants in the prevention and treatment of cancer-associated thrombosis is limited. In the EINSTEIN trials, comparing rivaroxaban to LMWH plus a vitamin K antagonist, only a small number of patients with active cancer received treatment with rivaroxaban (6.8% [n=118] in EINSTEIN-DVT1 and 4.7% [n=114] in EINSTEIN-PE2). The use of rivaroxaban over LMWH for cancer-associated thrombosis is not recommended by the current guidelines.3 However, due to the parenteral route of administration and high cost burden of LMWH, some cancer patients at our institution have received rivaroxaban for cancer-associated thrombosis. Method An observational chart review was performed to determine the effectiveness and safety of rivaroxaban for the treatment of VTE in cancer patients by observing recurrent VTE and bleeding events. For the effectiveness endpoint, patients who received rivaroxaban for less than one month were excluded from the study. For the safety analysis, patients who received at least one dose of rivaroxaban were included in the study. Result A total of 92 cancer patients with VTE who received rivaroxaban at Huntsman Cancer Institute were selected for the study. Median age was 60 years old and 54% (n=50) were male. Average estimated creatinine clearance at the initiation of rivaroxaban was 96.2 mL/min (range 31.8-241 mL/min, Cockcroft-Gault). Thirty-eight patients (41%) were treated for DVT (deep venous thromboses), 32 patients (35%) had PE (pulmonary embolism), and 19 patients (21%) had both DVT and PE. A total of 20 patients (21.7%) had a bleeding event while on therapy (see table). Ten patients (10.8%) experienced a major bleed and the median time to major bleeding was 4.4 months (IQR 2.4-11.6 months). One patient had a fatal intracranial bleed. Four patients (4.3%) had critical bleeding and 5 patients (5.4%) had a clinically relevant bleeding with ≥ 2g/dL drop in hemoglobin level and/or required ≥2 units of red blood cell transfusion. Pharmacodynamic interactions may have contributed to 3 major bleeds, including one patient on aspirin, another on ibuprofen, and the third patient on both aspirin and clopidogrel at the time of bleeding. Seven patients were taking rivaroxaban 20 mg daily at the time of the major bleed. The median platelet count at the time of bleeding was 170k/µL (IQR 108-333k/µL). One patient had a platelet count of 17 k/µL and was admitted with sepsis at the time of bleed. Ten patients (10.8%) experienced minor symptomatic bleeds and the median time to bleeding was 2.5 months (IQR 0.73-4.8 months). Only 4 patients (4.3%) experienced recurrent VTE while on rivaroxaban. Two patients had recurrent DVT. Two patients developed recurrent PE and both were admitted to the hospital for parenteral anticoagulation. The median time to recurrent VTE was 5.7 months (IQR 2.5-11 months). The median platelet count at the time of recurrence was 120 k/µL (range 26-216k/µL). One patient had a known thrombophilia, Factor V Leiden mutation. Conclusion These data suggest that rivaroxaban may be a safe and acceptable alternative to LMWH for the treatment and secondary prevention of cancer-associated thrombosis. Table 1.Huntsman Cancer Institute (n=92)EINSTEIN-DVT1(Cancer sub-group, n=118)EINSTEIN-PE2(Cancer sub-group, n=114)CLOT trial4(n=336)Major bleeding10.8% (n=10)14.4% (n=17)12.3% (n=14)14% (n=47)Clinically relevant non-major bleeding10.8% (n=10)Recurrent DVT2.2% (n=2)3.4% (n=4)n/a4.2% (n=14)Recurrent PE2.2% (n=2)n/a1.8% (n=2)3.9% (n=13) References: 1. Bauersachs R, Berkowitz SD, Brenner B, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N. Engl. J. Med. 2010;363(26):2499-2510. 2. Büller HR, Prins MH, Lensin AWA, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N. Engl. J. Med. 2012;366(14):1287-1297. 3. NCCN Clinical Practice Guidelines in Oncology. Cancer-Associated Venous Thromboembolic Disease, v2.2014. www.nccn.org. 4. Lee AYY, Levine MN, Baker RI, et al. Low-molecular-weight heparin versus a coumadin for the prevention of recurrent venous thromboembolism in patients with cancer. N. Engl. J. Med. 2003;349(2):146-153. Disclosures No relevant conflicts of interest to declare.

Tumor lysis syndrome (TLS) is an oncological emergency characterized by severe electrolyte disturbance that typically occurs when hematologic cancer patients have been started on systemic chemotherapy. We present an uncommon case of spontaneous TLS (STLS) occurring in a patient with cholangiocarcinoma. The patient was a 59-year-old male with newly diagnosed differentiated carcinoma of unknown origin who presented with weakness, fatigue, and lightheadedness. Initial imaging revealed cholangiocarcinoma with innumerable pulmonary and hepatic metastases. The laboratory values showed leukocytosis, hypercalcemia, and lactic acidosis. He was diagnosed and treated for sepsis of pulmonary origin. Over the next 3 days, the patient's clinical condition steadily worsened despite aggressive treatment, with newonset hypoxic respiratory failure, acute kidney injury, and septic shock. Chemotherapy was administered, with new laboratory values showing hyperuricemia and hyperkalemia, consistent with STLS. The patient was transferred to the ICU and emergently started on dialysis but expired a day later from multi-organ failure. To our knowledge, this is the second case of STLS in cholangiocarcinoma. Our patient was unique in that he presented with hypercalcemia and normal phosphorus levels, instead of the typical hyperphosphatemia and secondary consumptive hypocalcemia. While the exact pathophysiology of STLS is still elusive, we believe that the patient's initial sepsis-induced hypotension, aggressively enlarging tumor, and extent of metastasis all contributed to his rapid decline. Given the high mortality rate with TLS and its vague presentation, particularly in a chemotherapy-naïve solid tumor, a high level of clinical suspicion is needed to improve patients' outcome.

Background: Skeletal metastases (SM) in advanced pancreatic ductal adenocarcinoma (PDAC) is an infrequent occurrence that has been previously reported in literature to occur in less than 2.5% of the cases.Complications such as pathological fractures can result in intractable pain, immobilization and a significant deterioration in quality of life. The purpose of this study is to improve the understanding of the increasing incidence of SM and the importance of surveillance and adequate management of SM in these patients. Methods: A retrospective analysis was conducted using a clinical database at a single tertiary care institution for cancer patients; this included 207 patients with advanced PDAC diagnosed between December 2004 and March 2017 receiving palliative chemotherapy. SM were identified by computerized tomography (CT)/ fluorodeoxyglucose positron emission tomography (FDG-PET)/magnetic resonance imaging (MRI).Information regarding demographics, clinical course and date of last follow-up/death were collected. After a median follow-up of 11 months, an analysis was conducted, including a Kaplan-Meier survival analysis.Results: The study included 207 patients; 19 out of 207 patients (9.2%) developed SM; the primary tumor was located in the pancreatic body/tail in 12 out of 19 patients (63.2%). The thoracic and lumbar vertebrae were the most common sites of SM. Other common synchronous sites of metastases included the liver and lung. A majority of the lesions were osteolytic (63.2%). The median time of diagnosis from the initial diagnosis was 2 months (range, 0-60 months). Bone pain was observed as the initial symptom in 7 out of 19 patients (36.8%), 2 out of 19 patients (10.5%) had a pathological fracture and 1 out of 19 patients (5.3%) developed a para-spinal mass causing inferior vena cava compression. The median survival period for patients with SM was 11 months (range, 0-62 months) and for those without SM was 12 months (range, 0-147 months) [hazard ratio (HR) 1.24, 95% confidence interval (CI): 0.66-2.30, P=0.51].Conclusions: There has been a challenge with regards to management of the increasing number of patients with SM. Thoracic and lumbar vertebrae are the most common sites and pathological fractures in these sites can be catastrophic. Careful evaluation of skeletal signs and symptoms, early detection and intervention are essential to prevent morbidity and mortality from complications in patients with PDAC and SM.

We present a case of a 59-year-old male undergoing adjuvant chemotherapy for his pancreatic adenocarcinoma post-surgical resection. He had an acute rise in carbohydrate antigen (CA) 19-9 level, which raised suspicion of metastatic disease. Instead, the patient was diagnosed to have a liver abscess, the treatment of which brought the CA 19-9 level back to normal. Unfortunately, although CA 19-9 is Food and Drug Administration (FDA)-approved tumor marker for pancreatic cancer, it is also elevated in several benign conditions, causing fear of cancer and unnecessary diagnostic workup. Hence, caution is necessary for interpreting the significance of its elevation.