Abstract
Importance
A case of nasal septal perforation secondary to systemic bevacizumab therapy for ovarian cancer is reported. Bevacizumab is a vascular endothelial growth factor A (VEGF-A) inhibitor that is becoming more widely utilized in the oncologic community. There is only one prior report of septal perforation secondary to bevacizumab in the Otolaryngology specific literature. The purpose of this report is: 1) to raise awareness and discuss the literature surrounding the sinonasal complications of bevacizumab and 2) provide workup and treatment recommendations based on the sum of the available literature.
Observations
We review the clinical record of a 59 year old patient who presented with an anterior septal perforation while taking bevacizumab therapy for ovarian cancer. She had mild symptoms. Her oncologist held bevacizumab and topical moisture therapy was started. After several weeks, the perforation remained stable and bevacizumab was restarted for her ovarian cancer.
Conclusion and relevance
Bevacizumab is associated with both septal perforation and more widespread sinonasal toxicity. These lesions tend to produce only mild symptoms and can usually be managed conservatively. The decision to hold bevacizumab therapy should be made in conjunction with the patient and medical oncologist. Otolaryngologists should be aware of the toxicity from this increasingly common oncologic therapy.
1
Introduction
Bevacizumab is a monoclonal antibody inhibitor of vascular endothelial growth factor A (VEGF-A) which is currently FDA approved several late stage, solid tumor malignancies . The medication is also approved for epistaxis secondary to Hereditary Hemorrhagic Telangiectasia (HHT) . Over the last 10 years, several reports of bevacizumab induced nasal septal perforations have been described in patients treated for breast and colorectal cancer . More recently, bevacizumab has been associated with not only perforations but more widespread sinonasal toxicity . Despite these publications in the medical oncology literature, there is relatively sparse data in the Otolaryngology literature . The aims of this study are two-fold. First, this report will serve to raise awareness of the potential nasal toxicities secondary to systemic bevacizumab through case presentation and literature discussion. Secondly, based on the review of the literature, recommendations for work up and treatment are presented.
2
Report of case
A 59 year old female presents with an anterior septal perforation. This lesion occurred approximately 4 months prior. The patient blew her nose and removed several large crusts, after which she noticed the perforation. She was taking systemic bevacizumab for ovarian cancer. She had mild rhinorrhea but no other rhinologic symptoms. She had no history of prior nasal surgery, systemic inflammatory disease or cocaine abuse. No family history of autoimmune diseases. Her exam revealed a 0.5 cm anterior perforation with crusting ( Fig. 1 ). Bevacizumab was held for several weeks and topical moisture (nasal gel) was applied. The perforation remained stable and she re-started bevacizumab for her ovarian cancer.
2
Report of case
A 59 year old female presents with an anterior septal perforation. This lesion occurred approximately 4 months prior. The patient blew her nose and removed several large crusts, after which she noticed the perforation. She was taking systemic bevacizumab for ovarian cancer. She had mild rhinorrhea but no other rhinologic symptoms. She had no history of prior nasal surgery, systemic inflammatory disease or cocaine abuse. No family history of autoimmune diseases. Her exam revealed a 0.5 cm anterior perforation with crusting ( Fig. 1 ). Bevacizumab was held for several weeks and topical moisture (nasal gel) was applied. The perforation remained stable and she re-started bevacizumab for her ovarian cancer.
