In April 2009, in the setting of progression of metastatic disease to the liver, and based on promising antitumor activity in phase 2 trials,1 rapamycin 1 mg bid was added to octreotide long-acting release, currently at 60 mg IM monthly. All other medications were held constant. CT scan after approximately 8 weeks of treatment demonstrated significant decrease in the size of the hepatic metastases (Fig 1). For example, the liver lesion that had progressed, last measured at 4.3 cm, now measured 3.5 cm. The primary pancreatic mass decreased in size from 9.7 cm to 9.5 cm. Bilirubin improved, from 6.1 mg/dL immediately prior to initiating rapamycin to 1.6 mg/dL, whereas other liver function tests remained mildly elevated (Table 1). The dramatic decrease in the patient’s bilirubin was attributed to decrease in the size of hepatic metastases and accompanying improvement in intrahepatic biliary obstruction, a subtle finding on CT scanning. Distal esophageal varices were still present. At this time, the patient reported markedly decreased effort dyspnea. For instance, she was now able to exercise by climbing flights of stairs (NYHA class 2) and her 6-min walk test improved to 463 m. Echocardiogram demonstrated markedly improved right ventricular function and normal right ventricle size (right ventricular internal dimension at midchamber, end-diastole, on the apical four-chamber view, 3.3 cm), and repeat cardiac catheterization in July 2009 after 3 months of rapamycin demonstrated marked improvement: PA pressures 67/23/40 (systolic/diastolic/mean) mm Hg, PVR of 5.56 wu, cardiac index of 1.86 L/min/m2, and MVO2 of 71% (Table 1). PCWP was elevated on this catheterization, likely due to mild-to-moderate left ventricular diastolic dysfunction and consistent with echocardiogram findings earlier in the month. The patient developed a lower extremity rash on rapamycin, a common side effect, treated with antibiotics with partial resolution of the rash. The patient continued on rapamycin. By February 2010, she was functional NYHA class 1, her PA systolic pressure by echocardiogram was normal, and her EKG findings of right-side heart strain had resolved.