P2650 - Severe Gastric and Duodenal Ulceration with Bowel Perforation as Rare Immunotherapy Related Adverse Events in Hepatocellular Carcinoma: A Case Report

Award: Presidential Poster Award

TJ L. Wilson, MD¹, Tooba Tariq, MD¹, Mohamad I.. Itani, MD¹, Anusha Majagi, MD¹, Aabid Mohiuddin, DO¹, Leilah A. Tisheh, MD², Bashar Mohamad, MD^3
1Detroit Medical Center/Wayne State University, Detroit, MI; ²Long Island Community Hospital NYU Langone, Patchogue, NY; ³Wayne State University, Detroit, MI

Introduction: Immunotherapy has successfully become a staple in the treatment of numerous forms of cancer. One of the most commonly used drug combinations is Atezolizumab and Bevacizumab, which are immune checkpoint inhibitors (ICI) that target proteins Programmed Death Ligand-1 and Cytotoxic T-Lymphocyte-associated protein 4. This combination has become the mainstay of treatment for patients with unresectable Hepatocellular Carcinoma (HCC) who have not received prior systemic therapy. This combination has been shown to have an increased overall survival of 19.2 months. While it continues to be highly successful in the treatment of HCC, it is associated with adverse effects. Here, we present a case of a patient who developed multiple Immunotherapy-Related Adverse Events (IRAEs) after undergoing treatment with Atezolizumab and Bevacizumab for HCC.

Case Description/Methods: A 47-year-old male with HCC, being treated with Atezolizumab and Bevacizumab infusion once every three weeks, underwent screening Esophagogastroduodenoscopy (EGD) for varices. He was found to have multiple large and small gastric ulcers with heaped-up margins and an ulcerated duodenal mass. Biopsies of the mass were taken, sent, and reviewed by Pathology. Results showed granulation tissue and acute on chronic inflammation with ulceration without evidence of malignant cells. Therapy was continued, and shortly after, the patient presented with severe lower abdominal pain. CT abdomen without contrast was done and revealed a small bowel perforation that required a small bowel enterotomy. Immunotherapy was halted, and prior to resumption, another screening EGD was performed. EGD revealed multiple large and small deep gastric and duodenal ulcerations with a necrotic base (Figure).

Discussion: IRAEs stem from immune dysregulation and overreaction. It appears that ulcers are formed from nonspecific T-cell activation, resulting in inflammatory damage to the mucosa. Atezolizumab has common and relatively benign IRAEs that include skin reactions, fatigue, musculoskeletal and gastrointestinal issues, among others. However, eroding gastric ulcers and duodenal perforations are significantly less common, more severe, with a reported incidence of 1%. Other documented cases of bowel perforation after a short course of immunotherapy also presented in a similar fashion: abdominal distention and diffuse severe abdominal pain. While this is a rare complication of immunotherapy, prophylactic screening EGDs should be considered in patients starting immunotherapy.



Disclosures:


TJ L. Wilson, MD¹, Tooba Tariq, MD¹, Mohamad I.. Itani, MD¹, Anusha Majagi, MD¹, Aabid Mohiuddin, DO¹, Leilah A. Tisheh, MD², Bashar Mohamad, MD³. P2650 - Severe Gastric and Duodenal Ulceration with Bowel Perforation as Rare Immunotherapy Related Adverse Events in Hepatocellular Carcinoma: A Case Report, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.