Early-onset duodenal perforation during bevacizumab-containing chemotherapy in a patient with ovarian cancer: a case report

BACKGROUND: Bevacizumab-induced gastrointestinal perforation is a potentially fatal adverse event. However, duodenal perforations are rare. Conversely, patients with cancer often have concomitant rheumatoid arthritis and may be treated with a combination of anti-rheumatic drugs and symptomatic medications; however, the effects of these concomitant medications on bevacizumab-related perforation remain understudied. This report describes the case of a patient with ovarian cancer and a history of anti-rheumatic drug treatment who developed early-onset duodenal perforation during bevacizumab-containing chemotherapy, highlighting the importance of assessing the risk of duodenal perforation and the provision of multidisciplinary management. CASE PRESENTATION: The patient was a woman in her 50s with ovarian cancer that metastasized to the para-aortic lymph nodes. She was diagnosed with platinum-sensitive recurrence, and combination therapy with gemcitabine, carboplatin, and bevacizumab was initiated. She was also taking iguratimod and methotrexate for rheumatoid arthritis treatment. The patient developed sudden abdominal pain during the second course of chemotherapy and presented to the emergency department. A computed tomography (CT) scan revealed free gas, raising the suspicion of gastrointestinal perforation. Emergency laparotomy confirmed a duodenal perforation that was surgically covered with the ligamentum teres hepatis. A perforation of <1 cm was found in the anterior wall of the duodenal bulb, but the postoperative course was uneventful. The patient was discharged on postoperative day 7 and continued chemotherapy without bevacizumab. Postoperative upper endoscopy revealed an H2 stage ulcer. CONCLUSIONS: When administering bevacizumab to patients with ovarian cancer and multiple perforation risk factors, careful consideration should be given to evaluating existing ulcers, appropriately using concomitant medications, and modifying perforation risk factors to avoid serious adverse events. Therefore, collaboration between a multidisciplinary team, including oncologists, rheumatologists, and pharmacists, is crucial for appropriate drug use and continuous monitoring.