Pneumatosis intestinalis: a variant of bevacizumab related perforation possibly associated with chemotherapy related GI toxicity

Excerpt

A 54 year old male with metastatic low grade neuroendocrine tumor originating from the pancreas presents with air within the wall of the small intestine while receiving systemic chemotherapy plus bevacizumab. The patient had metastatic disease to the liver, peritoneum, and bone, and had received octreotide LAR injections for 2 years. Disease progression of the hepatic metastasis was found in February 2006 and he began systemic chemotherapy with oxaliplatin (130 mg/m²), S1 (30 mg; an oral fluoropyrimidine approved in Japan and under active investigation in the USA and Europe) and bevacizumab 7.5 mg/kg every 3 weeks, as per a clinical trial. The oxaliplatin was stopped after two months as per the study design and the patient continued on S1 and bevacizumab. Six months into treatment, a routine computed tomography (CT) revealed a small amount of pneumoperitoneum (Fig. 1), and extensive small bowel pneumatosis (Fig. 2). Except for constipation, the patient had no symptoms of fever, abdominal pain, nausea, or vomiting. He had no history of recent operative procedure, biopsy or endoscopy. His laboratory parameters were normal including a normal serum lactate. The S1 and bevacizumab were stopped and an adverse event was reported. The pneumatosis persisted on a CT scan performed 3 weeks following discovery, but subsequently resolved at 6 weeks. The patient remained asymptomatic throughout and was managed with close observation alone, and specifically without any invasive procedures.

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