Bevacizumab-induced esophageal pleural fistula during the maintenance therapy without radiation in lung cancer

Background: Esophageal pleural fistula (EPF) is a rare but fatal complication in the use of bevacizumab. Cases of EPF caused by bevacizumab have not been reported before.Case presentation: A 66-year-old male patient, who was diagnosed with stage IV lung adenocarcinoma at on 24th June, 2020, received 6 cycles of platinum containing dual chemotherapy combined with bevacizumab and 3 cycles of bevacizumab monotherapy. Five days before admission, he had obvious chest tightness, dyspnea, accompanied by right chest pain. Bed-side X-ray examination revealed a massive right hydrothorax, and food was found in the extracted pleural effusion. He was further confirmed with EPF by upper gastrointestinal radiography after an oral administration of Iohexol. This patient underwent jejunostomy since the distal esophagus could not be found in gastroscopy, and eventually died of septic shock on 16th January, 2021.Conclusion: It is necessary to pay attention of EPF during the use of bevacizumab whether the patient has risk factors or not.