[Intractable Hemorrhagic Duodenal Ulcer after Atezolizumab plus Bevacizumab Treatment for Hepatic Cancer with Lymph...

A 72-year-old woman with liver cirrhosis, diabetes, and parkinsonism was treated with atezolizumab plus bevacizumab (Atezo/Bev)for hepatic cancer and multiple lymph node metastases around the duodenum. After 2 doses of this treatment, alpha-fetoprotein(AFP)levels decreased, and the vascularity and size of the tumors were reduced on computed tomography. Eighteen days after the fourth dose of Atezo/Bev, the patient experienced shock due to bleeding from a duodenal ulcer and required hospitalization. Despite treatment with proton pump inhibitors, the duodenal ulcer did not show signs of healing and refractory duodenal ulcer bleeding occurred 102 days after the initial bleeding. AFP levels remained low and most of the tumors shrank, although new lymph node metastases were noted. Owing to the intractable duodenal ulcer and the intent for curative treatment of the hepatic cancer, resection of the liver, pancreatoduodenectomy with partial resection of the transverse colon, which was invaded by metastatic lymph nodes around the pancreatic head, and extirpation of the metastatic lymph nodes were performed. Pathological findings revealed that over 90% of the liver tumor was necrotic, and the residual viable lesion was adenocarcinoma, with a differential diagnosis of cholangiocarcinoma or cholangiolocellular carcinoma. The necrotic lesion possibly had a hepatocellular carcinoma component, and the liver cancer before Atezo/Bev treatment was possibly a combined hepatocellular-cholangiocarcinoma or cholangiolocellular carcinoma. The patient died of parkinsonism 1 year after surgery, without recurrence of liver cancer.