Gastropleural fistula from gastric perforation due to renal cell carcinoma after bevacizumab chemotherapy: a case report

A 39-year-old female was admitted for antibiotic treatment of sepsis of unknown origin, which had been empirically treated with piperacillin-tazobactam. The patient had previously (five months prior) been diagnosed with renal cell carcinoma with clear cell histological features and had undergone a left partial nephrectomy without excision of the entire tumor. Three months before admission, the patient was recruited to participate in a clinical trial investigating hepatic and pancreatic metastasis; the participants received interferon and bevacizumab in one of the protocols. The patient did not present any indication of pulmonary involvement from cancer in a tomography scan taken one month before admission. During her hospital stay, the patient presented a sudden onset of shortness of breath, tachypnea, and chest discomfort without hemodynamic repercussion. On physical examination, the patient exhibited decreased breath sounds in her left hemithorax and tympanic percussion. Trachea deviation was also observed to the right and the patient presented with bilateral jugular stasis. Her saturation was 91% despite oxygen given at a 10-l/min rate through an oxygen mask. A thoracocentesis with air escape in the second intercostal space was immediately performed by the thoracic surgeon. A left-sided hydropneumothorax was diagnosed in the chest roentgenogram with contralateral mediastinal shift (Figure 1). The patient was transferred to the intensive care unit (ICU) with chest discomfort despite drainage with a chest drain. A small amount of odorless, turbid brownish fluid came from the pleural space just after the drainage. After non-invasive mechanical ventilation, the chest discomfort progressively improved, and both lungs were expanded. Upon discharge from the ICU, a liquid resembling nasogastric feed started to emerge from the chest drain in increasing amounts and shortly after commencing feeding with an output of more than 2300 ml per day. Biochemical analysis of the pleural effusion revealed a neutrophilic exudate with a low pH (6.32), low protein (1.5 g/dl), normal glucose (103 mg/dl), and high levels of lactate dehydrogenase (DHL) and amylase (16864 U/l and 873 U/l, respectively). The level of serum amylase was 23 U/l. The cytological exam was inconclusive. Because of the high levels of amylase, an esophageal perforation was initially suspected. A methylene blue test was performed at the bedside with a positive result, indicating leakage of this substance in the chest drain insertion after oral administration. Computed tomography with oral contrasted medium through the feeding tube showed a gastropleural fistula originating from the greater curvature and extending to the left subphrenic space (Figure 2). The patient was submitted to parenteral nutrition. Two days after the diagnosis, the patient presented sudden bleeding exteriorized by the chest tube (approximately 1800 ml of sanguineous pleural effusion) and hypovolemic shock. The patient was transferred again to the ICU where the patient received fluid, blood, and vasopressor support and recovered from the shock. Upper gastrointestinal endoscopy revealed a large blood clot in the greater curvature and fundus, which impeded further exploration. The patient was submitted to embolization of the splenic arteries in the interventional radiology service with success, and no further bleeding episodes occurred. After discussion with the Gastro Surgery team and considering the surgical risk due to the patient’s poor status, the patient was transferred to a palliative care facility. The patient died ten days after the embolization, due to shock and acute respiratory insufficiency.