Bronchoscopy for bevacizumab-related hemoptysis

Summary

Bevacizumab is the first anti-angiogenic agent inhibiting vascular endothelial growth factor (VEGF) for treatment of patients suffering from cancer. Life-threatening hemoptysis is the most serious adverse effect of bevacizumab. The inhibition of VEGF is a possible mechanism involved in the destruction of normal lung tissue and subsequent hemoptysis. We report a case of bevacizumab-related hemoptysis and associated bronchoscopic findings that were successfully treated with rigid bronchoscopy and laser photocoagulation.

Introduction

Angiogenesis inhibitors are new targeted biological therapeutic agents that have a critical role in the treatment of cancer [1]. The humanized monoclonal antibody bevacizumab (Avastin™; Genentech Inc.), directly inhibiting vascular endothelial growth factor (VEGF), is the first anti-angiogenic agent for cancer therapy [2]. Since it was proven to show unprecedented survival benefit in patients with metastatic colorectal cancer, many clinical trials have been evaluating the potential of bevacizumab for patients with metastatic renal cell cancer, pancreatic cancer, breast cancer, and non-small cell lung cancer (NSCLC) [3].

The US Food and Drug Administration (FDA) has recently approved this agent in combination with carboplatin and paclitaxel for the initial systemic treatment of patients with unresectable, locally advanced, recurrent or metastatic, non-squamous, non-small cell lung cancer [4]. Neutropenia, fatigue, hypertension and infection are the most common adverse effects, but hemoptysis requiring medical intervention is seen in 2.3% of patients receiving bevacizumab and it can be fatal [5]. Recent studies of other new angiogenic inhibitors, such as sunitinib or sorafenib, also report fatal bleeding events in patients with advanced NSCLC [6]. It is therefore recommended that patients who develop these events should be excluded from clinical trials [7].

Because hemoptysis may be caused by malignant or infectious cavitary lung disease or by metastatic airway lesions, it is critical to identify the relationship of hemoptysis to the drug itself in cancer patients treated with angiogenesis inhibitors before stopping therapy. Herein, we report a case of bevacizumab-related hemoptysis and to the best of our knowledge, describe for the first time the associated abnormal bronchoscopic findings which were successfully treated using rigid bronchoscopy and laser photocoagulation.