SESSION TITLE: Cancer Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Wednesday, October 29, 2014 at 11:00 AM - 12:15 PM
INTRODUCTION: Bevacizumab is a humanised, monoclonal antibody against vascular endothelial growth factor (VEGF) used for treatment of advanced metastatic disease. Focal pulmonary hemorrhage has been observed in association with bevacizumab therapy; however diffuse alveolar hemorrhage (DAH) has not been reported.
CASE PRESENTATION: A 65 year old male former smoker with metastatic lung adenocarcinoma presented with three days of dry cough and dyspnea following his third cycle of bevacizumab, pemetrexed and paclitaxel. He was afebrile, tachypneic and hypoxic, and had bibasilar crackles on lung exam. His peripheral cell counts were normal and upper respiratory swab was positive for coronavirus. Non-contrast chest CT revealed new, diffuse ground-glass opacities and numerous stable metastases. Broad-spectrum antibiotics and high dose steroids for possible pneumonitis were initiated; however, the patient rapidly deteriorated, requiring mechanical ventilation. Diagnostic bronchoscopy revealed normal mucosa and no endobronchial secretions. Bronchoalveolar lavage (BAL) in the right middle lobe (minimal radiographic disease), appeared increasingly bloody, which was diagnostic of DAH. Malignant cells were identified on cytology and other causes of DAH were excluded. Despite escalation of steroids, he unfortunately expired on hospital day 17.
DISCUSSION: DAH is characterized by intra-alveolar accumulation of red blood cells, fibrin and hemosiderin-laden macrophages due to pulmonary microcirculation injury. Since VEGF maintains vascular integrity through endothelial cell proliferation, anti-VEGF therapy may impede regeneration of endothelial cells with chemotherapy, thereby predisposing to bleeding1.Bevacizumab could induce DAH by direct lung toxicity or due to a high disease burden made friable by cytolytic treatment. Although the mechanism of DAH in our patient cannot be confirmed, the absence of gross hemorrhage on bronchoscopy and no radiographic evidence of tumor at the site of BAL support bevacizumab as the most likely cause.
CONCLUSIONS: DAH should be considered as a potential complication of bevacizumab therapy in patients who develop acute respiratory symptoms and diffuse parenchymal infiltrates.
Reference #1: 1Hang XF1, Xu WS,et al. Risk of high-grade bleeding in patients with cancer treated with bevacizumab:a meta-analysis of randomized controlled trials. Eur J Clin Pharmacol.2011 Jun;67(6):613-2
DISCLOSURE: The following authors have nothing to disclose: Sakshi Sethi, Marc Feinstein, Robert Lee, Bianca Harris
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