Can tarceva induced ILD present in as little as 14 days on the drug? - 1254793

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teneo
Can tarceva induced ILD present in as little as 14 days on the drug? - 1254793

My mom healthy 72 yo dx stage 4 Adneocarcinoma stage 4 with plural effusion in late Aug 2012.
Vats surgery. Sept insert plural catheter 3 month draining, vats surgery Dec. remove Catheter, significant progression, left lung solid mass tumor, no mets else where, 2 rounds carboplatin/ Alimta Finally enough tissue from second vats to do EGFR test positive Exon 19 . Possible infiltrates on chemo in good right lung.
Stop chemo, start Tarceva, ween off steroid use by end of 5 th day on Tarceva. Day 7 Tarceva hoarse voice, continues through day 9 coupled with extreme tiredness no appetite. Also beginning to experience more SOB Day 12 grade 1-2 rash appears on scalp and face. Day 13 begins cough and still no appetite,
Day 15 thinking it may be bronchitis, calls onc. Begins antibiotic Day 16 chest x ray shows former left lung that was solid tumor 3/4 open, dramatic response to Tarceva, good right lung looks like infiltrates. Day 18 chest x ray at onc shows infiltrates in good lung, confirms dramatic response in left lung with tumor, orders bronchoscopy. Waiting with worry. Mom's now on O2 24 hours and needs 4 liters, previous to taking Tarceva, she did take 2 liters O2 to give her a boost during the night.

Our Onc. does not think it is Tarceva related ILD since, it is happening so early in treatment.
My question is have any of you seen ILD early on in the use of Tarceva?

Since the Pulminologist could not definitively say it was not ILD, so the Onc. told her to stop Tarceva for 4 days do a CT on Monday while we wait for results from the Bronchoscopy.

Thanks for you Time,
Teneo

JimC
Reply To: Can tarceva induced ILD present in as little as 14

Since it's a hypersensitvity reaction to Tarceva, it can occur quickly, as discussed previously: http://cancergrace.org/forums/index.php?topic=2403.0

JimC
Forum moderator

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

teneo
Reply To: Can tarceva induced ILD present in as little as 14

Thanks,
We will wait and pray for a different result, but knowing that at least we stopped the Tarceva for now is the right move. Thanks for your quick response.

Dr West
Reply To: Can tarceva induced ILD present in as little as 14

I haven't seen enough ILD to say much here, though I agree it's absolutely possible to have it come on quickly. If there's any significant chance of ILD, the typical recommended course of action is to discontinue Tarceva (erlotinib) unless or until ILD is ruled out.

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

teneo
Reply To: Can tarceva induced ILD present in as little as 14

Thanks Dr. West,
Although disheartening, we have stopped the drug. My mother is depressed as I think we are out of treatment options since Alimta and Carboplatin did not work.
We will see what pathology comes up with on Tuesday.
Teneo

marisa93
Reply To: Can tarceva induced ILD present in as little as 14

Just want to offer my best wishes...

Lisa

teneo
Reply To: Can tarceva induced ILD present in as little as 14

Well, it has been a few weeks since I first posted my question. We were in the mayo hospital for about 8 days. 2 broncoscopies, a biopsy, plural fluid tap, and 2 consulting pulmonologists a fellow, and about 6 interns saw my Mom everyday, we went through about 5 days of antibiotics including vancomycin
. No infection, her O2 needs went from 2 liters only at night before we went to the hospital to 10 liters on a pendent cannula 24 hours and the only activity was to pivot to the comode and she would desaturate into the 70's, finally on day 6 they give her steroids, and low and behold she begins to feel much better. by day two of the steroids she is down to 4 liters of O2, and now at home she is on about two liters on a regular cannula.

They basically say we have no idea why she had the infiltrates as they had started before she went on Tarceva, but are saying it must be Tarceva induced because they can not find anything else.

My question is could she have had an underlying inflamation going on since she was treated for vasculitis with heavy steroids in her eye right before we started carbo and alimta?
She would get SOB whenever they would wean her from the steroids and then get better as they would bump the steroids before she got her next IV chemo.
She only did two rounds of this before starting Tarceva, when they said the infiltrates were worse on the IV chemo than when she started.
She is EGFR positive exon 19 and saw a left lung that was completely tumor reopen 3/4 of the way. in 17days on Tarceva. It was an incredible response.
Do you think they might rechallenge the Tarceva at a lower dose. She was on the 150mg. would they ever consider Tarceva with steroids? I know I am grasping for something to hang on to. Just hoping for any other options you all might have if they are not wanting to rechallenge the Tarceva?
Would she have the same reaction to Iressa?
Any other ideas?

Thanks,
Teneo

catdander
Reply To: Can tarceva induced ILD present in as little as 14

Hi Teneo, It's good that your mom is breathing easier on steroids. It isn't unusual for people to need to stay on them longer than first expected.
I'll let our doctors give input on the tarceva question.

All best,
Janine

Dr West
Reply To: Can tarceva induced ILD present in as little as 14

It sounds like there is some reason to wonder whether her inflammatory condition may be related to an auto-immune process connected to her vasculitis rather than to the Tarceva. I think your idea of continuing steroids to manage the inflammatory and potentially auto-immune process while then trying a well-monitored re-challenge with Tarceva would be a real possibility, though it's well in the range of individual judgment. I don't believe that Tarceva at a lower dose would be significantly safer it it's really causing a severe inflammatory response like interstitial lung disease (ILD).

I don't know whether all patients who have an ILD response to Tarceva (erlotinib) would have the same response to Iressa (gefitinib) and vice versa, but that would be my fear. I've never heard of a patient who developed ILD being challenged with the other.

Good luck. I hope you'll keep us posted on developments.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

teneo
Reply To: Can tarceva induced ILD present in as little as 14

Dr West,
Thanks so much. I will let you know what our Oncologist says.
I appreciate the input.
Teneo

teneo
Reply To: Can tarceva induced ILD present in as little as 14

Dear Dr. West,
My mom is now breathing on room air during the day and back down to 2 liters of O2 at night. I wanted to pass along some research I found while searching for answers on rechallenging Tarceva after ILD with either the addition to steroids, reduced dose or changing TKI drug. Will see Onc in one week. Miraculous recovery for Mom.

http://www.ncbi.nlm.nih.gov/pubmed/22579408
Lung Cancer. 2012 Aug;77(2):464-8. doi: 10.1016/j.lungcan.2012.04.013. Epub 2012 May 12.
Successful erlotinib rechallenge for leptomeningeal metastases of lung adenocarcinoma after erlotinib-induced interstitial lung disease: a case report and review of the literature.

http://journals.lww.com/jto/Fulltext/2010/07000/Successful_Erlotinib_Rec...
Successful Erlotinib Rechallenge after Gefitinib-Induced Acute Interstitial Pneumonia

http://synapse.koreamed.org/Synapse/Data/PDFData/0003TRD/trd-67-445.pdf
CopyrightⒸ2009. The Korean Academy of Tuberculosis and Respiratory Diseases. All rights reserved.
Recurrent Erlotinib-Induced Interstitial Lung Disease on Non-Small Cell Lung Cancer

http://jjco.oxfordjournals.org/content/early/2012/03/28/jjco.hys042.full
Clinical Impact of Switching to a Second EGFR-TKI After a Severe AE Related to a First EGFR-TKI in EGFR-mutated NSCLC

http://www.ncbi.nlm.nih.gov/pubmed/22457323
Clinical impact of switching to a second EGFR-TKI after a severe AE related to a first EGFR-TKI in EGFR-mutated NSCLC.

http://pubmedcentralcanada.ca/articlerender.cgi?accid=PMC3220897
Copyright © 2011 by S. Karger AG, Basel
Erlotinib Achieved Partial Response in a Non-Small Cell Lung Cancer Patient with Gefitinib-Induced Interstitial Lung Disease

http://www.ncbi.nlm.nih.gov/pubmed/22579408
Lung Cancer. 2012 Aug;77(2):464-8. doi: 10.1016/j.lungcan.2012.04.013. Epub 2012 May 12.
Successful erlotinib rechallenge for leptomeningeal metastases of lung adenocarcinoma after erlotinib-induced interstitial lung disease: a case report and review of the literature.

Dr West
Reply To: Can tarceva induced ILD present in as little as 14

Thanks very much for sharing this information. It's quite helpful.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

teneo
Reply To: Can tarceva induced ILD present in as little as 14

Dr. West,
We met with our Oncologist and they are going to wean my mom down to 10 mg of steroid over the next two weeks. She will then re-challenge the Tarceva at 100 mg dose, along with 10 mg steroid. The chest X-ray showed the infiltrates had resolved in her good lung and showed a little progression in her lung that had been complete tumor that the tarceva had opened up 3/4 of the way. She will stay on the steroid at least initially during the start back on Tarceva, and we will monitor her breathing. She is back breathing on room air and is able to do activity, although at a slower pace. This is a miracle as she was up to 10 liters in the hospital and de saturating into the 70's with just a pivot from bed to commode, before going back on steroids. I will update again after we rechallenge. No response needed, Thanks for all you do on this site. No need for you to respond.

teneo
Reply To: Can tarceva induced ILD present in as little as 14

Quick update May8, 2013... Mom dropped to 10 mg prednizone and was having shortness of breath, after 3 days, The Oncologist bumped her up to 15 mg and she had less shortness of breath. She rechallenged Tarceva on Sunday night May 5th, 2013 at 100 mg. Today is day 3, she is feeling good and we are watching for signs of reaction. I will update as we go but for now she is back on the Tarceva and feeling pretty good.

JimC
Reply To: Can tarceva induced ILD present in as little as 14

Hi teneo,

Thanks for the update. That's great to hear that your Mom is back on Tarceva and feeling good, and I hope that continues!

JimC
Forum moderator

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

Dr West
Reply To: Can tarceva induced ILD present in as little as 14

Thanks for the info. I definitely have people who have lung inflammation for one reason or another and feel a definite difference in dose of prednisone of just 5-10 mg.

Good luck with the rechallenge, and thanks for keeping us posted.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

teneo
Reply To: Can tarceva induced ILD present in as little as 14

Dr. West,
We just returned from Mom's Onc visit. My mom looks and feels better and stronger each day. She has been on Tarceva at 100mg and 15mg prednisone. The lung with the infiltrates looks remarkable clear, and the Tarceva is melting more of the tumor away in the lung that had the solid tumor. She will stay the course on the tarceva but is trying to lower her prednisone so she will go 15mg one day and 10 mg the next for two weeks to see if we can get it lowered with out compromising her breathing. Her potassium is a bit high so she will get that retested next week again, but otherwise things are pretty good. We are guardedly excited. I wanted to pass along the good news. She was able to vacuum, and rake outside and her SAT is not dropping below 88 and bounces right back into the 90's when she takes a break. She has the normal side effects of a bit of diarrhea, small rash so far on face and more on scalp, since we were only on it for 17 days before and it has only been 14 days now we will see if she has manageable side effects on the 100mg dose. We are just so thrilled and wanted to let you know.

catdander
Reply To: Can tarceva induced ILD present in as little as 14

teneo, That's such fantastic news! I understand being guardedly excited but that's ok, you're mom is out about doing...
Breathe,
Janine

Dr West
Reply To: Can tarceva induced ILD present in as little as 14

I agree that's terrific to hear, and it's helpful as well, since I haven't had a patient in a similar situation before. It's good to know what's possible and raise that possibility for others.

Good luck -- here's to favorable reports for a very long time.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

teneo
Reply To: Can tarceva induced ILD present in as little as 14

It has been about a month since I last updated on my mom. She is feeling great! She has reduced her Oxcodone (she takes this for breathing ease not pain) to one dose a day. She has weaned down to 7mg of Prednisone a day and and uses a nebulizer one time a day. She is completely off O2 even at night.

It is such a miracle from April to now. She is now walking 2 miles a day and just stained her deck this past week. The side effects remain very mild and manageable. Much less for her on 100 mg than on 150mg.

Tarceva has given her wonderful quality time with both her four grown children but most importantly to her with her 15 grandchildren. It is just a miracle. Her last scan did not show any new cancer growth, but her infiltrates in her lung with out the cancer looked better in the xray and there was no new cancer growth in the lung that had been a solid mass tumor it has remained open and the Dr. can hear air being exhanged there where he could hear nothing before the Tarceva.

catdander
Reply To: Can tarceva induced ILD present in as little as 14

FANTASTIC! I'm so glad your mom is feeling good. The grandkids are so lucky for the additional time and pampering I know.

I hope this last a long long long time.
Janine

teneo
Reply To: Can tarceva induced ILD present in as little as 14

Another update:
My mom is now past her 1 year anniversary of dx in August. She is still doing great on 100 mg of Tarceva and 7 mg of Prednisone. She is off all other medications including Oxycodone and is walking 4 miles a day. She has minimal side effects, and is hoping to drop to 5 mg steroid in a couple of weeks. She turned 73 in July and last week was out raking leaves (single handily raked 20+ bags of leaves last week.) It is a miracle.

I wanted to give some hope to those that have experienced ILD type symptoms. It is not always fatal and to those on Tarceva , it was worth the risk.I think my family would say it was worth the risk even though she almost died and could have died. Now it is is holding her cancer stable.
After seeing dramatic results at first we are now seeing stable scans. She will go back in December. For now she is living a full and active life. We are richly blessed.

Thanks to you all on this website for all of your information as it is so helpful. She would not be alive with out the caring support of people on the Grace Lung cancer site and Inspire lung cancer site. We have gleaned so much helpful information from these two sites. Thank you again.

catdander
Reply To: Can tarceva induced ILD present in as little as 14

teneo, What WONDERFUL news! 4 miles+ 20+ bags=1 big happy extended family.
I know how you all held your breath, but you made brave decisions that paid off and your mom is showing us all what is possible.

Let me add that my husband is shoveling roofing from the side of the house as I write. He peeled 5/6 layers of roofing from 1/2 our house this summer. I couldn't be more happy that he's able to take these risks of further damage.

teneo, you and I are the lucky ones and I'm so glad you're sharing you mom's good fortune with the community.

One thought about coming off the steroid. It has to be slow slow slow and can only be judged by how she reacts. It's a very individual process.

Congratulations!
Janine

Dr West
Reply To: Can tarceva induced ILD present in as little as 14

Thanks for sharing such wonderful news as well as your assessment of the ILD and news that it can be managed effectively. Since few if any oncologists have any critical mass of experience with ILD, given that it's something seen in only 0.5-2% of people receiving an EGFR inhibitor, getting insight from others is always helpful.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education