Gastric Perforation Presenting as Empyema in a Patient with Pancreatic Cancer on Bevacizumab Treatment

Case Report

A 57-year-old man previously who underwent curative resection for pancreatic tail cancer had tumour recurrence 8 months later. The recurrent tumour grew around the splenic flexure of the colon and attached to the greater curvature of the stomach. Upon surgical exploration, we deemed curative resection was deemed inapplicable because the tumour had spread into the peritoneal cavity. Thus, a palliative colectomy was performed with an ileo-sigmoidostomy to resolve partial colonic obstruction. Thereafter, the patient was placed on systemic erlotinib and gemcitabine therapy. Three months later, the patient presented with symptoms of tumour progression with postprandial epigastralgia and vomiting. Upper gastrointestinal endoscopy revealed submucosal tumours in the upper and middle gastric body. The patient was then placed on salvage therapy of bevacizumab (10 mg/m², IV for 90 min, bi-weekly), gemcitabine and oxaliplatin twice between mid-May and early-June, 2007. His symptoms were alleviated.

One week after the second dose of bevacizumab-based chemotherapy, the patient developed fever and dyspnea, but had no abdominal symptoms. A chest radiography showed a left loculated pleural effusion without subphrenic free air (Figure 1) and thoracentesis revealed a purulent effusion. Microscopic examination of the pleural effusion revealed gram-negative rods. To explore the aetiology of the empyema, the patient underwent computed tomography of chest and abdomen, which showed fluid accumulation with air-fluid levels in the left lower thorax and pancreatic tail region (Figure 2A and B). The cultures of the pleural effusion and ascites fluid both yielded Klebsiella pneumoniae. Bowel perforation with formation of intra-abdominal abscesses and empyema was suspected. The patient then underwent upper gastrointestinal barium study, which confirmed gastric perforation with a fistula connecting to the peripancreatic abscess (Figure 3). The patient was placed on cefepime antibiotic therapy and a tube thoracotomy and percutaneous intra-abdominal abscess drainage were performed. The patient did not undergo surgery due to his advanced tumour status.

The patient received cetuximab-containing salvage chemotherapy after the infection was controlled. In the meantime, the surveillance cultures of the abdominal abscess grew various organisms, including Klebsiella pneumoniae, Citrobacter freundii and Candida albicans. The patient received antimicrobial therapy accordingly. Despite these measures, tumour progression continued and he died of uncontrollable infection 2 months after the development of empyema.

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Figure 1.

A chest radiograph showing loculated pleural effusion in the left thorax.