Published online Jun 27, 2023. doi: 10.4240/wjgs.v15.i6.1232
Peer-review started: January 12, 2023
First decision: January 21, 2023
Revised: January 30, 2023
Accepted: April 19, 2023
Article in press: April 19, 2023
Published online: June 27, 2023
Processing time: 154 Days and 1.1 Hours
The combination of atezolizumab (ATZ) and bevacizumab (BVZ) was approved as first-line systemic therapy for advanced hepatocellular carcinoma (HCC) owing to its superior rates of response and patient survival. However, ATZ + BVZ is associated with increased risk of upper gastrointestinal (GI) bleeding, including arterial bleeding, which is rare and potentially fatal. We present a case of massive upper GI bleeding from a gastric pseudoaneurysm in a patient with advanced HCC who had been treated with ATZ + BVZ.
A 67-year-old man presented with severe upper GI bleeding after atezolizumab (ATZ) + bevacizumab (BVZ) therapy for HCC. Endoscopy failed to detect the bleeding site. Digital subtraction angiography revealed a gastric artery pseudoaneurysm and contrast extravasation from the inferior splenic artery and a branch of the left gastric artery. Successful hemostasis was achieved with embolization.
HCC patients who have been treated with ATZ + BVZ should be followed for 3 to 6 mo to monitor for development of massive GI bleeding. Diagnosis may require angiography. Embolization is an effective treatment.
Core Tip: Atezolizumab (ATZ) + bevacizumab (BVZ) treatment increases the risk of bleeding in hepatocellular carcinoma (HCC) patients. Gastrointestinal (GI) bleeding is most common and usually arises from esophageal varices. We report a patient with advanced HCC who presented with massive upper GI bleeding from a gastric artery pseudoaneurysm after three cycles of ATZ + BVZ. Gastric artery pseudoaneurysm is rare and often asymptomatic. Mortality is high and emergency endovascular embolization is required. Patients receiving ATZ + BVZ treatment should be followed closely for GI bleeding. Arterial bleeding should be considered when massive GI bleeding occurs. Angiography may be required for diagnosis. Embolization has a role in treatment.