Case Report Occult Gastrointestinal Perforation in a Patient With EGFR-Mutant NoneSmall-Cell Lung Cancer Receiving Combination Chemotherapy With Atezolizumab and Bevacizumab: Brief Report Ashray Gunjur, 1 Geoff Chong, 1,4 Adeline Lim, 2 Eddie Lau, 3 Paul Mitchell, 1,5 Thomas John, 1,5,6 Surein Arulananda 1,5,6 Clinical Lung Cancer, Vol. -, No. -, --- Crown Copyright ª 2019 Published by Elsevier Inc. All rights reserved. Keywords: Bevacizumab, EGFR-mutant, Gastro-oesophageal perforation, NSCLC, SABR Introduction The management of nonesmall-cell lung cancer (NSCLC) has undergone a rapid and evolutionary transformation in the past 2 decades. This includes the use of combination platinum doublet chemotherapy and immune checkpoint inhibition for advanced squamous and nonsquamous NSCLC, resulting in impressive survival gains compared to chemotherapy alone in patients without targetable oncogenic drivers. 1-3 In patients with epithelial growth factor receptor (EGFR)-mutant and anaplastic lymphoma kinase (ALK)-rearranged NSCLC, pa- tients inevitably experience disease progression as a result of a variety of resistance mechanisms after therapy with tyrosine kinase in- hibitors. Given the heterogenous nature of resistance pathways, generic strategies aimed at disease control are likely to be more feasible for most patients. One of these strategies is described in the phase 3 IMpower150 study, which not only confirmed an overall survival (OS) benefit with the quadruplet combination of platinum- paclitaxel chemotherapy, atezolizumab, and bevacizumab (ABCP) in the intention-to-treat wild-type population but also in the subset of patients with sensitizing EGFR mutations and ALK rearrange- ments who have experienced disease progression while receiving tyrosine kinase inhibitor therapy. 4,5 This is especially important given the outcomes with single-agent programmed cell death pro- tein 1 (PD-1) axis inhibitors, which are suboptimal in patients with these molecular alterations. 6 Clinical Practice Points Clinical Practice Points  Combination atezolizumab, bevacizumab, carbopla- tin, and paclitaxel (ABCP) is an evidence-based treatment strategy for patients with metastatic epithelial growth factor receptor (EGFR)emutant or anaplastic lymphoma kinase (ALK)-rearranged none small-cell lung cancer progressing after therapy with tyrosine kinase inhibitors.  Clinicians should be aware of the toxicity profile of ABCP, particularly the risk for potentially fatal gastrointestinal toxicity from bleeding or perforation.  There may be synergistic toxicity risk when combining bevacizumab with intra-abdominal stereotactic abla- tive radiotherapy (SABR), with symptoms potentially manifesting months later. Any patient receiving bev- acizumab with abdominal pain who has previously received SABR should be carefully evaluated for gastrointestinal toxicity. 1 Department of Medical Oncology 2 Department of Radiation Oncology 3 Department of Radiology 4 Department of Medicine, University of Melbourne, Austin Health, Melbourne, Australia 5 Cancer Immuno-Biology Laboratory, Olivia Newton-John Cancer Research Institute, Heidelberg, Australia 6 School of Cancer Medicine, La Trobe University, Heidelberg, Australia Submitted: Aug 4, 2019; Revised: Nov 12, 2019; Accepted: Nov 22, 2019 Address for correspondence: Surein Arulananda, MBBS, La Trobe University, Olivia- Newton John Cancer Research Institute, Department of Medical Oncology, Heidel- berg, Australia E-mail contact: surein.arulananda@austin.org.au 1525-7304/$ - see frontmatter Crown Copyright ª 2019 Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.cllc.2019.11.014 Clinical Lung Cancer Month 2019 - 1