Intramedullary Spinal Cord Hemorrhage after Treatment with Bevacizumab in a Long-term Survivor with Metastatic Non–Small-Cell Lung Cancer

Abstract

A 49-year-old Hispanic male with stage IV non-squamous, non-small-cell lung cancer (NSCLC) on maintenance bevacizumab treatment, presented with progressive paresthesias over the back, abdomen, and chest; left foot numbness; unsteady gait; and mid-back pain. He had been diagnosed with advanced lung cancer 14 months prior, including bulky thoracic adenopathy, brain metastases, and malignant pleural and pericardial effusions. Imaging demonstrated no spinal, dural, or vertebral lesions. He was initially treated with pericardiectomy and whole brain radiation therapy (RT), followed by administration of six cycles carboplatin-paclitaxel plus bevacizumab then 12 cycles of bevacizumab maintenance monotherapy. To evaluate the patient's neurologic symptoms, magnetic resonance imaging (MRI) of the spine was performed, which suggested the presence of intramedullary spinal cord metastases (ISCM) at the T4 level, with associated hemorrhage (Fig. 1A, B). Additional imaging revealed stable disease elsewhere. He was started on systemic steroids, and bevacizumab was discontinued. Neurosurgery was consulted with recommendation against surgical intervention. RT (45 Gray/25 fractions) was delivered to the intramedullary metastases. Back pain resolved, neurologic symptoms improved, and steroids were discontinued. MRI evaluation after RT demonstrated reduction in size of the metastases with resolution of hemorrhage. (Fig. 1C, D). Discussion This could be the first reported case of bevacizumabassociated intramedullary hemorrhage in NSCLC. ISCM is a rare event, reported to affect only 0.1-0.4% of cancer patients and typically associated with poor prognosis. 1 Of these cases, approximately 55% are attributed to lung cancer. 1 Clinical