 I'm going to be presenting a case of an elderly patient with metastatic RCC with multiple cardiovascular risk factors. No disclosures. And treatment of patients with molecularly targeted therapy has raised new challenges in regards to management of associated adverse events. And these toxic events differ from those associated with traditional chemotherapy and warrant special consideration and management. And the point of this talk is to really highlight selected toxicity and highlight adverse events, monitoring and management. So we start with a 77-year-old male with multiple medical problems. In 2006, he presents with abdominal pain. Imaging confirms a six-centimeter right renal mass without vessel or nodal involvement. He undergoes a right radical nephrectomy showing clear cell RCC, grade two of four, and margins are negative. And he's followed with serial imaging, and in February of 2013, imaging confirmed relapsed disease. And you can see here he has bilateral pulmonary nodules and a right hyalur mass on CT imaging. He undergoes a CT-guided biopsy of the left lower lobe lung nodule. And here we see neoplastic cells with clear cytoplasm that are arranged in nests, was intervening blood vessels consistent with clear cell RCC, similar to his primary tumor. And cells are positive for Pax VIII and negative for TTF-1. In regards to his past medical history, he has a history of coronary disease. He's status post MI in 1990, requiring stent placement and five-vessel cabbage in 2001. He has a triple A and a status post to stent for that. He has hypertension, diabetes. He's not on insulin, has a baseline hemoglobin A1C of seven, and has chronic renalysis efficiency with a baseline creatinine of 1.8 to two. His allergies include aspirin, so he can't take aspirin, and his medications are plavix, metoprolol, metformin, glimeparide, synvestatin, and temsilosin. So we had him see oncocardiology for follow-up of the DFCI before initiating any therapy. He did have a stable blood pressure in the 120s to 70s. EKG showed a normal sinus rhythm, but he did have evidence of prior infarct. He had an echo with a baseline EF of 50 to 55 percent. With some mild enteroceptal hypokinesis, his triple A was stable without evidence of endo-leak on imaging, and to optimize his cardiovascular regimen, he was started on lysineprol 2.5 milligrams. So we see him in clinic and start him on Pozopin, a dose reduced at 600 milligrams daily given his age and comorbidities. And following a month of therapy, he experiences profound fatigue, nausea, and diarrhea, calls our clinic, and we hold therapy. And just a couple of days later, he develops significant hematichesia, is actually admitted to an outside hospital, undergoes a colonoscopy, which shows evidence of ischemic colitis. This was suspected to be secondary to dehydration in the setting of low blood pressure and profound diarrhea and nausea, poor oral intake. He couldn't undergo an angiography given his renal function. And this is not this patient's colonoscopy, but a representative colonoscopy of a patient with ischemic colitis. In panel A, you see normal mucosa. In panel B, you see erythematous, edematous, erosive mucosa, and the corresponding pathology, you have the mucosa is eroded in panel C, and you see this fibropurulent exudate in panel D with hyalinization of the mucosa. So we see him in clinic a couple of weeks later. Imaging confirms disease response with shrinkage of the pulmonary nodules and the right hyalur mass. We continue to follow him with imaging, and two months from his event, he has mild progression on imaging. And at that point in time, we decide to restart him on Pizopina, but 200 milligrams daily. And then he's followed again, and one month later, we repeat his imaging, and he again has a confirmed response. He's tolerating pozzofine. He continues on therapy at 200 milligrams, mild diarrhea, no fatigue, and a stable blood pressure. Here you see his imaging from July of 2013, and that was the impetus to reinitiate the pozzopinib, and then confirmed response at 200 milligrams with the imaging in August. So in summary, treatment with pozzopinib-worn special consideration in elderly patients with cardiovascular risk factors, dose modifications may be warranted and do not necessarily preclude response to therapy. Excellent. And I'd like to acknowledge Tony, Michelle Hurst, our pathologist. Gloria will be our nurse practitioner, Javid Mosley, who's our cardio-oncologist that we refer all our patients to.