IntroductionPegylated liposomal irinotecan (nal-IRI) in combination with fluorouracil (5-FU) and leucovorin (LV) has achieved a median overall survival of 6.1 months in patients with metastatic pancreatic ductal adenocarcinoma (mPDAC) who progressed on gemcitabine-based chemotherapy. The case of a patient with considerable long-term survival on second-line nal-IRI-based therapy is presented.Case presentationA 70-year-old male presented with weight loss and abdominal pain in July 2018, was diagnosed with stage IB PDAC (pT2, pN0, M0), and underwent successful R0 resection. Adjuvant chemotherapy with FOLFIRINOX (5-FU, LV, irinotecan, and oxaliplatin) was given for nine cycles between September 2018 and January 2019, and the patient remained recurrence-free until a computed tomography scan revealed soft tissue mesenteric infiltrations in July 2020. First-line palliative chemotherapy with nab-paclitaxel + gemcitabine was initiated and continued until January 2022 when disease progression in the form of two metastatic hepatic lesions was observed. Second-line palliative chemotherapy with nal-IRI 129 mg on day 1 + capecitabine (CAP) 4000 mg daily for the first 7 days of each 14-day cycle was initiated (due to previous 5-FU intolerance). Response (reduced oncomarkers) was observed, and treatment with nal-IRI + CAP continued, with liver-directed treatment in September 2023, until February 2024. During second-line therapy, side effects (mild diarrhoea) were infrequent and manageable.Conclusion This patient achieved an extraordinary survival of 25 months with second-line treatment with nal-IRI + CAP. Nal-IRI-based therapy has the potential to provide long-term survival in the presence of favourable prognostic factors such as moderately elevated CA 19-9 levels.

IntroductionPegylated liposomal irinotecan (nal-IRI) in combination with fluorouracil (5-FU) and leucovorin (LV) has achieved a median overall survival of 6.1 months in patients with metastatic pancreatic ductal adenocarcinoma (mPDAC) who progressed on gemcitabine-based chemotherapy. The case of a patient with considerable long-term survival on second-line nal-IRI-based therapy is presented.Case presentationA 70-year-old male presented with weight loss and abdominal pain in July 2018, was diagnosed with stage IB PDAC (pT2, pN0, M0), and underwent successful R0 resection. Adjuvant chemotherapy with FOLFIRINOX (5-FU, LV, irinotecan, and oxaliplatin) was given for nine cycles between September 2018 and January 2019, and the patient remained recurrence-free until a computed tomography scan revealed soft tissue mesenteric infiltrations in July 2020. First-line palliative chemotherapy with nab-paclitaxel + gemcitabine was initiated and continued until January 2022 when disease progression in the form of two metastatic hepatic lesions was observed. Second-line palliative chemotherapy with nal-IRI 129 mg on day 1 + capecitabine (CAP) 4000 mg daily for the first 7 days of each 14-day cycle was initiated (due to previous 5-FU intolerance). Response (reduced oncomarkers) was observed, and treatment with nal-IRI + CAP continued, with liver-directed treatment in September 2023, until February 2024. During second-line therapy, side effects (mild diarrhoea) were infrequent and manageable.Conclusion This patient achieved an extraordinary survival of 25 months with second-line treatment with nal-IRI + CAP. Nal-IRI-based therapy has the potential to provide long-term survival in the presence of favourable prognostic factors such as moderately elevated CA 19-9 levels.