Sudden aortic dissection: A cautionary tale for the unexplained back pain during bevacizumab treatment

Bevacizumab is widely used in the treatment of colorectal cancer, liver cancer, and other advanced solid tumors because of its multiple targets, no genetic testing and better safety. Globally, the use of bevacizumab in the clinic has been climbing year by year based on several large-scale, multicenter prospective studies. While bevacizumab undeniably has a good clinical safety profile, it has also been associated with adverse effects such as drug-related hypertension and anaphylaxis. In our recent clinical work, we met a female patient with acute aortic coarctation previously treated with multiple cycles of bevacizumab, who was admitted with sudden onset of back pain. Because the patient had just had an enhanced CT of the chest and abdomen a month earlier, no abnormal lesions apparently associated with low back pain were found. So when the patient was seen on this occasion, our clinical diagnosis was first considered to be neuropathic pain, but a further multiphase enhancement CT was done again for further exclusion and the final diagnosis was acute aortic dissection. The patient later died within 1 hour after the chest pain had worsened again while waiting for a surgical blood supply within 72 hours of presentation. The risk of fatal acute aortic dissection is not sufficiently emphasized in the revised instructions for bevacizumab, although the adverse effects associated with aortic dissection and aneurysm are mentioned. Our report is of high practical value in raising clinicians’ vigilance and safe management of patients using bevacizumab worldwide.