Dear Editor, Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, is an arteriovenous malformation of various organs and systems due to fibrovascular dysplasia. This results in recurrent and sometimes severe bleeding, of which epistaxis is the most common. Hepatic arteriovenous malformations may cause arteriovenous shunting within the liver, ischemic hepatobiliary damage, and high-output cardiac failure [1]. A 73-year-old man whose 2 brothers and 18 of 31 relatives also suffer from HHT was treated over the previous years with multiple blood transfusions for occult gastrointestinal hemorrhage but remained consistently anemic (hemoglobin level of 60 g/l). Since the last 3 years the patient also suffered from a malignant mesothelioma and therefore received six courses of chemotherapy with cisplatin/gemcitabine from March to October 2004, leading to disease stabilization. Due to disease progression, he was treated with four courses of FOLFOX4 (oxaliplatin, leucovorin, and fluorouracil) from March to June 2005 and ten courses of doxorubicin until

November 2005. Due to new progression of the disease, we decided to apply pemetrexed (500 mg/m2, q 3 weeks) and bevacizumab (5 mg/kg, q 2 weeks); the latter is a recombinant humanized monoclonal antibody to vascular endothelial growth factor (VEGF) and is thought to be an active drug for malignant mesothelioma [2]. Because it was suggested that increased production of VEGF is responsible for HHT [3], we also wanted to evaluate the effect of bevacizumab in transfusion frequency. The patient was treated exclusively at our institution, receiving frequent endoscopies of the upper and lower gastrointestinal tract and repeated small bowel examinations. Multiple argon beamer coagulations in the last months due to vascular malformations in the upper gastrointestinal tract were applied. As can be seen in Fig. 1 there was a dramatic decrease in transfusion frequency and improvement of hemoglobin concentration immediately after treatment with bevacizumab. Before the onset of treatment, we diagnosed multiple arteriovenous shunts in the liver by selective coeliacography. Increased cardiac output, as assessed by echocardiography, decreased from 7,800 ml/min to 6,900 ml/min after five courses of bevacizumab. Moreover, the patient’s performance status significantly improved. In the first staging after three courses of pemetrexed and six courses of bevacizumab, there was no progression of malignant mesothelioma as assessed by computed tomography.