DR McDERMOTT: It can be challenging with people who have lung metastases, to separate what’s lung toxicity from what’s disease progression. And oftentimes you don’t settle that until you see a scan. So the key is education and not treating through worsening symptoms until you do an evaluation. Sometimes you have to get a pulmonary consult to try to separate what’s infection from what’s drug toxicity.
DR LOVE: Dave?
DR QUINN: If patients have some minor symptoms, we’ll add some prednisone, which will suppress that. It’s when they become significantly symptomatic into Grade 3 where you need to assess what’s going on. You may need to give steroids. You may want to break therapy. And if you think they could have an infection, they need to be actively investigated. That doesn’t happen very often, but the mTOR group of drugs have some immunosuppression as part of their activity. They’re derived and homologs of sirolimus. And so we have seen a handful of infections in the lung. And if patients get sick, they need to be actively investigated. It doesn’t happen very often, but it’s important.
DR LOVE: Bob, any comment about mucositis with everolimus? This is a huge topic in breast cancer nowadays, because they’re just starting to get used to this drug. There, they use a lot of preemptive corticosteroid mouthwashes, et cetera. How do you approach the issue of prevention and management?
DR MOTZER: What we’ve found to be the most effective are the steroid mouthwashes. And there’s also a paste that they can buy to actually put it over the lesion. So that seems to be quite effective in managing the stomatitis. It also seems like — I don’t treat breast cancer, but it seems like the stomatitis may be a little bit more of an issue in the breast cancer population than in the kidney cancer population, for reasons that I don’t quite understand.
Sometimes these patients can get herpes stomatitis as well. As David mentioned, it’s an immune suppressant. And so you need to distinguish the stomatitis from the drug to infections like a herpes infection. But usually they’re just an area of lysis in the mucosa that is very focal. It’s not diffuse. It usually occurs under the tongue or on the gums. And we’ve been quite successful in managing it with the corticosteroids. If it’s not amenable to that sort of treatment, though, then the patient needs to be dose-reduced.