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Case Report
Bilateral pneumothorax after bevacizumab-containing chemotherapy in Fibrosarcoma: A case report
Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical College, No. 151, Yanjiang Rd, Guangzhou, Guangdong, China
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Abstract
Bevacizumab-containing therapies can improve outcomes in patients with sarcoma. Bevacizumab had several notable adverse effects including bowel perforation but bilateral pneumothorax had never been reported in the available English literature. We reported a 23-year-old male with poorly differentiated fibrosarcoma who had spontaneous bilateral spontaneous pneumothorax (SP) after the third cycle of bevacizumab-containing chemotherapy. His bilateral pneumothorax resolved after closed drainage of pleural cavity with a small caliber catheter. The mechanism of pneumothorax developed after bevacizumab therapy was not clear. In patients who had chest discomfort after bevacizumab-containing therapy, pneumothorax should never be overlooked as one of the differential diagnoses.
Key words
Pneumothorax; fibrosarcoma; bevacizumab; chemotherapy; small caliber catheter
J Thorac Dis 2012;4(2):229-231: 10.3978/j.issn.2072-1439.2012.01.03
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Introduction
Bevacizumab is a monoclonal antibody that binds and inactivates all isoforms of VEGF to inhibit angiogenesis and tumor growth and proliferation. It can improve outcomes in patients with sarcoma (1). Bevacizumab has several notable adverse effects including bleeding, hypertension, heart failure, proteinuria, thromboembolism and gastrointestinal (GI) perforation, an uncommon but serious adverse effect (2-4). However, bilateral SP occurring after bevacizumab-containing chemotherapy had never been reported in the literature. Herein, we present a case of bilateral pneumothorax occurring after bevacizumab-containing chemotherapy.
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Case report
A 23-year-old man had a complaint of swelling and intermittent pain in the right thigh for two months before admission to the Surgical Department of our hospital. Physical examination showed significant swelling of the right thigh. Whole body PET/CT (Figure 1) demonstrated a large heterogeneous lesion located in the right iliac foss and no evidence of lung metastasis. Right inguinal lymph node biopsy was low-grade fibrosarcoma. Bevacizumab (5 mg/kg) and DP (docetaxol 75 mg/m2, cisplatin 75 mg/m2) every 21days were prescribed as first-line chemotherapy. The right thigh swelling was better than before. The patient had sudden-onset chest pain and dyspnea 13 days after the third cycle of Bevacizumab plus DP (day 55 after initial chemotherapy). Physical examination showed decreased breath sounds of the chest. Compared with the previous chest radiograph (Figure 2), a bilateral pneumothorax was disclosed (Figure 3). The pneumothorax resolved completely after chest tube drainage. The chest tube was removed 3 days later. In the fourth chemotherapy, bevacizumab was not used and pneumothorax was not occurred. However, in the fifth chemotherapy, we add the bevacizumab again, chest radiograph showed right pneumothorax a week later after bevacizumab (Figure 4). The pneumothorax resolved completely after chest tube drainage. The chest tube was removed 7 days later and the follow-up radiograph did not show recurrence of the pneumothorax. At the same time, we never use the bevacizumab again.
Figure 1. Whole body PET/CT demonstrated a large heterogeneous
lesion located in the right iliac foss.
Figure 2. Chest radiography before treatment shows no lung
metastases.
Figure 3. Chest CT shows bilateral pneumothorax after three cycles
of bevacizumab containing chemotherapy.
Figure 4. Chest radiography shows right pneumothorax after the
fifth chemotherapy.
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Discussion
Bevacizumab has several notable adverse effects including bleeding, hypertension, heart failure, proteinuria, thromboembolism and gastrointestinal (GI) perforation and so
on, but secondary SP especial bilateral SP after bevacizumabcontaining
therapies is a rare. Sarcomas appear to be the
malignancy most often associated with SP (5,6). There were
some sarcoma patients with bilateral SP during chemotherapy
where pulmonary metastases were not detectable. This suggests
that SP was either a coincidence or rather a complication of very
small metastases adjacent to the pleura (7,8). In this case, when
we used bevacizumab, SP was occurred, and when we did not
use bevacizumab, there was not SP. On this basis of the above,
we speculate that the pneumothorax in our patient was likely an
adverse effect of the bevacizumab.
The risk factors for bevacizumab associated pneumothorax
are unclear. In this case, metastatic lesions could not be noted
in the initial chest radiography and CT, we presume that
micrometastases were occurred before it could be detected by imaging studies. Several theories regarding possible mechanisms
of the bilateral penumothourax in sarcomas have been put
forward. First, the rupture of a subpleural bleb in a patient with
an underlying chronic pulmonary disease is possible. Second,
tumor nodules may act as ball valves to produce a partial
bronchiolar obstruction and hyperinflation of alveoli. The
rupture of an emphysematous bulla in an overexpanded portion
of the lung produces a pneumothorax (9).
Early detection of lung metastases is difficult, and Furrer
et al. suggested that imaging studies such as chest radiography
and CT are suboptimal for detecting micro-lesions and that
sometimes pneumothorax could be the first and only evidence
for metastases (10).
The pneumothorax after bevacizumab therapy was easily
treated with a small caliber chest tube. A small caliber chest tube
is considered as effective in management of an uncomplicated
pneumothorax as a large caliber chest tube (11), and it can
avoid a large wound and decrease the risk of bleeding from
a large caliber chest tube, which is especially important due
to the concerns of bleeding and delayed wound healing with
bevacizumab therapy.
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References
Cite this article as: Zhang Y, Yang H, Zhao M, He J. Bilateral pneumothorax
after bevacizumab-containing chemotherapy in fibrosarcoma. J Thorac Dis
2012;4(2):229-231. doi: 10.3978/j.issn.2072-1439.2012.01.03
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