"Spontaneous," delayed colon and rectal anastomotic complications associated with bevacizumab therapy

Late anastomotic colonic dehiscence due to antiangiogenic treatment, a specific drug-class complication requiring specific treatment: an example of pazopanib complication

Bevacizumab, a recombinant humanized monoclonal antibody against vascular endothelial growth factor (VEGF), was the first angiogenesis inhibitor approved for the first-line treatment of metastatic colorectal cancer in combination with intravenous fluorouracil-based chemotherapy. Two major cohort studies--BRiTE and BEAT--reported a 2% incidence of bowel perforation, which remains a rare, but serious, complication of bevacizumab treatment. Late anastomotic complications, arising > 3 months after surgery, are emerging occurrences that may be associated with bowel perforation. We report here on such a case caused by pazopanib, a new antiangiogenic agent, and also include a review of the published cases in the literature (n = 23) and an analysis of their management. Proctectomy was the initial surgery in 17 patients (74%) with rectal cancer, and 13 of these patients had undergone adjuvant radiation prior to surgery. The majority (84%) of the complications occurred with antiangiogenic treatment after a mean number of four cycles. Patients' management was invariably associated with withdrawal of the antiangiogenic agent, together with conservative treatment in 14 patients (66%).

Biologic modulation of chemotherapy in patients with hepatic colorectal metastases: the role of anti-VEGF and anti-EGFR antibodies

In the treatment of metastatic colorectal cancer, the subset of patients with liver-only metastases shows the greatest promise for prolonged survival and cure. Advances in surgery and medical treatment have encouraged multimodality treatment strategies and therefore require a true multidisciplinary approach. The current standard of care includes peri-operative chemotherapy and surgery. The new era of biologically targeted therapy requires an in-depth look at the possible efficacy and risks of adding these agents to the treatment protocol.

Bevacizumab and ocular wound healing after primary pterygium excision

PURPOSE

The aim of this study was to evaluate the effect of subconjunctival bevacizumab on early postoperative wound healing in patients with primary pterygium excision.

METHODS

In this randomized, double-blind, placebo-controlled study, the patients were randomized into 2 groups. Group 1 (G1) received a total of 7.5  mg bevacizumab (5  mg/0.2  mL on the day of surgery and 2.5  mg on the fourth day after surgery). Group 2 received 0.2  mL balanced salt solution at the end of surgery. Postoperatively, patients were examined at 1 day, 1 week, and 1 month. The following parameters were evaluated: horizontal length of the corneal epithelial defect (in millimeters), conjunctival erythema, conjunctival flap edema, subconjunctival hemorrhage, lacrimation, and photophobia. Any complications of conjunctival flaps such as retraction and melting or wound infection were recorded.

RESULTS

There were no statistically significant differences for age, sex, operated eye, and horizontal size of pterygium among 44 eyes of 44 patients, 22 in each group. No patient had conjunctival flap melting or retraction, keratitis, or nonhealing corneal epithelial defect. No statistically significant differences were observed between the groups for the evaluated measures except for conjunctival erythema at the first postoperative day (P = 0.005), which was more common in G1. Although the horizontal length of corneal epithelial defect in G1 was twice that of group 2 on the seventh postoperative day (average 0.09 vs. 0.04  mm, range 0-1 vs. 0-0.3  mm), the difference was not statistically significant (P = 0.45).

CONCLUSION

No adverse effect on early postoperative wound healing of excised primary pterygium was observed in patients who received subconjunctival bevacizumab.

Recurrent abscess after primary successful endo-sponge treatment of anastomotic leakage following rectal surgery

AIM: To assess long-term efficacy of initially successful endo-sponge assisted therapy.

METHODS: Between 2006 and 2009, consecutive patients who had undergone primary successful endo-sponge treatment of anastomotic leakage following rectal cancer surgery were enrolled in the study. Patients were recruited from 6 surgical departments in Vienna. Clinical and oncologic outcomes were assessed through routine endoscopic and radiologic follow-up examination.

RESULTS: Twenty patients (7 female, 13 male) were included. The indications for endo-sponge treatment were anastomotic leakage (n = 17) and insufficiency of a rectal stump after Hartmann’s procedure (n = 3). All patients were primarily operated for rectal cancer. The overall mortality rate was 25%. The median follow-up duration was 17 mo (range 1.5-29.8 mo). Five patients (25%) developed a recurrent abscess. Median time between last day of endo-sponge therapy and occurrence of recurrent abscess was 255 d (range 21-733 d). One of these patients was treated by computed tomography-guided drainage and in 3 patients Hartmann’s procedure had to be performed. Two patients (10%) developed a local tumor recurrence and subsequently died.

CONCLUSION: Despite successful primary outcome, patients who receive endo-sponge therapy should be closely monitored in the first 2 years, since recurrence might occur.

Liver resection remains a safe procedure after neoadjuvant chemotherapy including bevacizumab: a case-controlled study

OBJECTIVE

This study was conducted to analyze if the combination of Bevacizumab with standard chemotherapy increases postoperative morbidity and mortality after resection of colorectal liver metastases as compared with resection after chemotherapy alone. Parameters contributing to an increased morbidity were evaluated.

SUMMARY BACKGROUND DATA

Most patients referred for colorectal liver metastases are treated with neoadjuvant chemotherapy before hepatic surgery. Targeted agents like the vascular endothelial growth factor-antagonist Bevacizumab are increasingly added to standard therapy to prolong survival; however, little is known about the consequences of this policy in the perioperative period.

METHODS

One hundred-two patients treated between 2005 and 2009, who received neoadjuvant chemotherapy combined with Bevacizumab (CHT + B) were identified. A cohort of 112 patients treated without chemotherapy alone before resection served as the control group (CHT). Complications were graded within an established staging system and the therapeutic consequences were laid down. Uni- and multivariate analysis of factors contributing to postoperative complications in the CHT + B group was performed using a logistic regression model.

RESULTS

Postoperative complications occurred in 45 (44%, CHT + B) and 38 (34%, CHT) patients, respectively (P = 0.216). The incidence of severe complications requiring surgical or radiologic intervention or leading to organ failure was 10.8% in the CHT + B group and 7.1% in the CHT group (P = 0.350). Increased age, low serum albumin, resection of more than 3 liver segments and synchronous bowel procedures requiring an anastomosis were associated with an increased morbidity rate in the multivariate regression analysis. No patient died in either group.

CONCLUSIONS

The addition of Bevacizumab to standard chemotherapy before resection of colorectal liver metastases does not seem to increase postoperative morbidity. Caution should be given to extended resections >3 liver segments and synchronous bowel anastomoses.

Complications of perineal surgery

Anorectal procedures are associated with significant morbidity and include complications of the perineum, which can cause substantial difficulty for the patient. Prevention of perineal complications is key, but many anorectal procedures are performed in difficult situations such as large bulky tumors or inflammatory bowel diseases. In this review, the authors outline many of the complications encountered following both simple and complex anorectal procedures while highlighting best evidence for treatment.

Understanding and managing the possible adverse effects associated with bevacizumab

PURPOSE

The adverse events associated with bevacizumab therapy are characterized, and the underlying pathophysiology, risk factors, frequency, and management of these events are described.

SUMMARY

The adverse events associated with bevacizumab include hypertension, proteinuria, thromboembolism, impaired wound healing, bleeding, perforation, reversible leukoencephalopathy syndrome, skin rash, and infusion-related hypersensitivity reactions. Patients should be monitored for these events throughout the course of bevacizumab therapy. Hypertension is by far the most common adverse event associated with bevacizumab. Blood pressure should be routinely monitored, and hypertension should be medically managed with antihypertensive drugs as deemed appropriate during bevacizumab therapy. Patients should be monitored for proteinuria every three to four weeks, and bevacizumab should be discontinued with persistent proteinuria of >2+. Thromboembolic events, impaired wound healing, bowel and nasal septum perforation, and bleeding share similar pathophysiology. Thromboembolic events should be managed in accordance with guidelines established by the American College of Chest Physicians, and bevacizumab should be discontinued for new life-threatening venous or arterial thromboembolism. To minimize the risk of bleeding or impaired wound healing, bevacizumab should be started at least four weeks after surgery or discontinued for at least six to eight weeks before elective surgery. The management of other adverse events is more anecdotal, with relatively few reports of their occurrence with bevacizumab.

CONCLUSION

Many of the potential serious complications of bevacizumab can be averted by close monitoring of patient-specific variables, which should be measured at baseline and then at predetermined intervals throughout the course of therapy to maximize patient safety.

Bevacizumab-related surgical site complication despite primary tumor resection in colorectal cancer patients

BACKGROUND

Combining conventional systemic chemotherapy with the angiogenesis inhibitor bevacizumab is now recommended as a first treatment for metastatic colorectal neoplasms. The risk for short-term postoperative complications related to bevacizumab has been assessed. Late postoperative complications related to bevacizumab have also been suggested by preliminary reports.

METHODS

We reviewed a cohort of 142 patients with previous surgery for primary colonic or rectal tumor and without evidence of local recurrence, receiving bevacizumab for metastatic disease.

RESULTS

Four patients experienced a late surgical site complication related to bevacizumab. Common features were rectal location, low anastomosis, and preoperative irradiation. Combining these three factors, the risk of a bevacizumab-related complication was 4 in 27 (14.8%); if previous history of postoperative leakage was reported, the risk was raised to 2 in 4. No complications occurred in colonic location or the non-irradiated patients. The mechanism of these complications could be ischemic lesion in post-irradiated tissues involving anastomoses.

CONCLUSION

We conclude that angiogenesis inhibitors should be carefully considered for patients having low colorectal anastomosis and previous irradiation.

Spontaneous rectovaginal fistula during bevacizumab therapy for ovarian cancer: a case report

Recent studies have demonstrated efficacy of bevacizumab for recurrent ovarian cancer, but few data on its use and gastrointestinal potential complications when administered as adjuvant chemotherapy after cytoreductive surgery are available. In this study, we report the first case of a rectovaginal fistula in this indication.

Bowel perforation in non-small cell lung cancer after bevacizumab therapy

BACKGROUND

Bevacizumab is increasingly used in combination with chemotherapy for treatment of unresectable non-small cell lung cancer. The aim of this report is to underline possible risks associated with this otherwise well-tolerated drug.

PATIENT

A 69-year-old patient with metastatic non-small cell lung cancer was started on a palliative chemotherapy regimen containing carboplatin, paclitaxel, and bevacizumab.

RESULTS

After the second cycle of chemotherapy, the patient developed abdominal pain. On emergency laparotomy, there was diffuse perforation of the colonic wall, so the patient underwent a Hartmann's procedure with subtotal colectomy. Histopathological examination confirmed the diagnosis of ischemic colitis.

CONCLUSION

Gastrointestinal perforation is a known adverse event of bevacizumab therapy which so far has occurred only in patients with predisposing risk factors. Our patient illustrates that there must always remain a high index of suspicion regarding bowel perforation in patients developing acute abdominal pain under bevacizumab therapy, even if they have no apparent risk factors.