PATHOLOGY J Oral Maxillofac Surg xx:xxx, 2012 Unusual Bevacizumab-Related Complication of an Oral Infection Michèle Magremanne, MD, DDS,* Morgan Lahon, MD, DDS,† Joke De Ceulaer, DDS, MD,‡ and Hervé Reychler, MD, DMD§ Bevacizumab is a recombinant humanized monoclo- nal antibody and blocks angiogenesis by binding to vas- cular endothelial growth factor. Indications for bev- acizumab are metastatic colorectal cancer, metastatic breast cancer, metastatic nonsmall cell lung cancer, and glioblastoma. The side effects of bevacizumab therapy can be severe and include thromboembolic episodes, hypertension, hemorrhage, gastrointestinal perforation, and wound-healing complications. Con- versely, osteonecrosis of the jaw (ONJ) related to bevacizumab treatment is rare and was first reported by Estilo et al 1 in 2008. Since then, only a few cases have been described. 2-5 The authors present the first case of an unusual bevacizumab-related complication of an oral infection limited to the soft tissue. Report of Case A 49-year-old man with a history of a right temporal lobe glioblastoma multiforme was diagnosed and treated surgi- cally on March 18, 2010. He subsequently underwent radi- ation therapy (60 Gy) and concomitant chemotherapy with temozolomide from April 6, 2010, to May 17, 2010. The radiation field did not include the oral cavity or the jaw bone. Adjuvant chemotherapy with temozolomide was ad- ministrated every 5 weeks until February 2011. Because of a local evolution and a cerebral herniation on March 2011, he was reassessed for additional surgery (de- compression) and received a single injection of beva- cizumab 10 mg/kg on April 25, 2011. He had no history of bisphosphonate therapy, but corticosteroids were part of his treatment. One week after the injection of bevacizumab, the patient presented with dental pain and infection in the left poste- rior mandible, which was treated first with clindamycin 300 mg 3 times/day. The left mandibular first molar was ex- tracted 1 week later (May 10, 2011) because of dental mobility and the persistence of pain and infection. Careful curettage of the alveolus was performed. There was no abnormal bone exposure around the site of extraction. The adjacent teeth presented neither mobility nor decay. Clin- damycin was administrated the first 5 days postoperatively in combination with a chlorhexidine oral rinse. The evolu- tion was uneventful for 3 weeks, but, unfortunately, the patient developed cellulitis for which he took clindamycin on his own initiative. He presented to the outpatient clinic 1 week later (June 6, 2011) with a large upper cervical and paramandibular swelling of approximately 10 cm in diameter. Intraoral examination showed a 1.5-cm mandibular bone exposure in the region of the extracted tooth and vestibular bulging. Panoramic radiography showed no periapical or periodon- tal lesions. The abscess was drained to the oral cavity. The same day, he presented with an important intraoral bleed- ing. The day after, a skin infiltration from the left cheek to the clavicle was noted. Under general anesthesia, oral examina- tion showed a large dehiscence of the mucosa at the junc- tion of the unattached and attached gingiva. The entire vestibular part of the left mandible was exposed from the angle to the midline (Figs 1, 2). The circumjacent mucosa appeared poorly vascularized. There was no more evidence of acute infection. There was no tooth mobility, the cortical bone did not show any area of necrosis. Five mm after its emergence from the foramen, the mandibular nerve was necrotic, and the facial artery in the region of the mandib- ular notch was necrotic. The overlying skin presented an altered aspect. Computed tomographic scan showed a soft tissue infil- tration of 35  25  43 mm. There was no evidence of osteonecrosis of the mandible. Large soft tissue debridement by intra- and extraoral ac- cess (Fig 3) was performed on June 8, 2011, and necrotic skin, fat tissue, and muscle were removed. The necrotic Received from the Department of Oral and Maxillofacial Surgery, Saint-Luc University Hospital and Cancer Center, Université Catholique de Louvain, Brussels, Belgium. *Consultant, Department of Oral and Maxillofacial Surgery, Saint- Luc University Hospital and Cancer Center, Université Catholique de Louvain, Brussels, Belgium. †Resident, Department of Oral and Maxillofacial Surgery, Centre Hospitalier Universitaire Ambroise Paré, Mons, Belgium. ‡Resident, Department of Oral and Maxillofacial Surgery, Saint- Luc University Hospital and Cancer Center, Université Catholique de Louvain, Brussels, Belgium. §Head of Department of Oral and Maxillofacial Surgery, Saint-Luc University Hospital and Cancer Center, Université Catholique de Louvain, Brussels, Belgium. Address correspondence and reprint requests to Dr Magre- manne: Department of Oral and Maxillofacial Surgery, Cliniques universitaires Saint-Luc, Université catholique de Louvain, 10, ave- nue Hippocrate, B-1200 Brussels, Belgium; e-mail: magremanne .michele@gmail.com © 2012 American Association of Oral and Maxillofacial Surgeons 0278-2391/12/xx0x-0$36.00/0 http://dx.doi.org/10.1016/j.joms.2012.03.022 1