Correspondence

Response of a Nonmalignant Pleural Effusion to Bevacizumab

N Engl J Med 2005; 353:740-741August 18, 2005

Article

To the Editor:

The potential role of vascular endothelial growth factor in malignant as well as nonmalignant pleural effusion1,2 prompted us to use bevacizumab, a monoclonal antibody against vascular endothelial growth factor, in a 68-year-old man with primary cardiac amyloidosis who had severe dyspnea and underwent repeated thoracenteses for pleural effusions. Cytologic assessments of the pleural fluid did not detect malignant cells. Primary amyloidosis had been diagnosed by myocardial biopsy four weeks previously, but there were no other manifestations of amyloidosis. At the time of the patient's admission, left ventricular function was moderately reduced (ejection fraction, 40 percent). A radiograph of the chest showed massive pleural effusion in the right hemithorax. The C-reactive protein level was markedly increased (27.2 mg per deciliter), but no inflammatory infiltrate was seen in the radiograph of the lung. Thoracentesis was unsuccessful because of the segmented nature of the effusion. Because of the elevated C-reactive protein level, we began broad-spectrum antibiotic treatment and gave the patient an intravenous diuretic. After five days, the C-reactive protein level was reduced, but the clinical condition, with severe dyspnea, and the chest radiograph remained unchanged. The patient was judged unable to undergo anesthesia for surgical intervention and pleurodesis.

Because the severe dyspnea continued despite intensive conventional treatment for another seven days, we decided to treat the patient with bevacizumab (Avastin, Roche).3 After obtaining the patient's consent, we administered the dose used for the treatment of colorectal cancer (5 mg per kilogram of body weight given intravenously over a period of 90 minutes).4 On the first day after the administration of bevacizumab, the patient reported increased urine production and markedly reduced dyspnea. One week after bevacizumab treatment, the chest radiograph showed a dramatic reduction in the pleural effusion. This finding was confirmed in a second radiograph two weeks after the administration of bevacizumab.

To our knowledge, this is the first report of the treatment of a nonmalignant pleural effusion with bevacizumab. Considering the prompt clinical improvement and the reduction in the effusion after administration of the antibody, there is good reason to believe that clinical improvement and diminished effusion were associated with bevacizumab therapy.

Oskar Pichelmayer, M.D.
Christoph Zielinski, M.D.
Markus Raderer, M.D.
Medical University of Vienna, 1090 Vienna, Austria
markus.raderer@meduniwien.ac.at

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Citing Articles (11)

Citing Articles

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   Stavros Anevlavis, Argyris Tzouvelekis, Demosthenes Bouros. (2012) Mechanisms of Pleural Involvement in Orphan Diseases. Respiration 83:1, 5-12
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   H. Yabe, M. Yabe, T. Koike, T. Shimizu, T. Morimoto, S. Kato. (2010) Rapid improvement of life-threatening capillary leak syndrome after stem cell transplantation by bevacizumab. Blood 115:13, 2723-2724
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   Eleanor K Mishra, Robert JO Davies. (2010) Advances in the investigation and treatment of pleural effusions. Expert Review of Respiratory Medicine 4:1, 123-133
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   Suk-Hyang Bae, Jin Yeon Hwang, Woo Jae Kim, Hyun-Hwa Yoon, Jung Min Kim, Young Hee Nam, Hee Gyung Baek, Yong Rak Cho, Sun-Yi Park, Jeong Hwan Kim, Sung-Hyun Kim, Tae-Ho Park, Gi-Nam Lee, Seo-Hee Rha, Young Dae Kim. (2010) A Case of Cardiac Amyloidosis With Diuretic-Refractory Pleural Effusions Treated With Bevacizumab. Korean Circulation Journal 40:12, 671
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   Sabrina C.C. RIBEIRO, Francisco S. VARGAS, Leila ANTONANGELO, Evaldo MARCHI, Eduardo H. GENOFRE, Milena M.P. ACENCIO, Lisete R. TEIXEIRA. (2009) Monoclonal anti-vascular endothelial growth factor antibody reduces fluid volume in an experimental model of inflammatory pleural effusion. Respirology 14:8, 1188-1193
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   Masaki Watanabe, Julie L. Boyer, Ronald G. Crystal. (2009) Genetic Delivery of Bevacizumab to Suppress Vascular Endothelial Growth Factor-Induced High-Permeability Pulmonary Edema. Human Gene Therapy 20:6, 598-610
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   K. Prassl, A. Sahanic, B. Reicher, H. Denz, M. Freund, M. Fiegl. (2008) Striking response with bevacizumab and chemotherapy in a woman with heavily pretreated breast cancer: a case presentation. memo - Magazine of European Medical Oncology 1:3, 149-151
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   Joseph F. Poduslo, Muthu Ramakrishnan, Silvina S. Holasek, Marina Ramirez-Alvarado, Karunya K. Kandimalla, Emily J. Gilles, Geoffry L. Curran, Thomas M. Wengenack. (2007) In vivo targeting of antibody fragments to the nervous system for Alzheimer’s disease immunotherapy and molecular imaging of amyloid plaques. Journal of Neurochemistry 102:2, 420-433
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   Robert J. Hoyer, Nelson Leung, Thomas E. Witzig, Martha Q. Lacy. (2007) Treatment of diuretic refractory pleural effusions with bevacizumab in four patients with primary systemic amyloidosis. American Journal of Hematology 82:5, 409-413
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    Ioannis Kalomenidis, Georgios T. Stathopoulos, Randal Barnette, Spyros Papiris, Timothy S. Blackwell, Charis Roussos, Richard W. Light. (2007) Vascular endothelial growth factor levels in post-CABG pleural effusions are associated with pleural inflammation and permeability. Respiratory Medicine 101:2, 223-229
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    Steven E Mutsaers, Ioannis Kalomenidis, Nicola A Wilson, YC Gary Lee. (2006) Growth factors in pleural fibrosis. Current Opinion in Pulmonary Medicine 12:4, 251-258
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