Myocarditis as an immune-related adverse event following treatment with ipilimumab and nivolumab combination therapy for metastatic renal cell carcinoma: a case report.

Abstract

BACKGROUND:

Immune checkpoint inhibitors are new immunotherapy drugs globally used for many malignancies, including renal cell carcinoma. Myocarditis as an immune-related adverse event is rare but highly fatal, suggesting that its frequency may be higher than reported. This paper describes a case of myocarditis that developed asymptomatically following ipilimumab and nivolumab combination therapy for renal cell carcinoma.

CASE PRESENTATION:

A 71-year-old Asian man who presented to hospital with fever, fatigue, and weight loss of approximately 10 kg within 2 months was diagnosed with Xp.11.2 translocation renal cell carcinoma. Computed tomography revealed multiple lung masses, mediastinal lymph node enlargement, and a level II tumor thrombus reaching the inferior vena cava (cT3bN0M1; International Metastatic Renal Cell Carcinoma Database Consortium, poor risk). Ipilimumab/nivolumab combination therapy was started as induction therapy. The patient experienced acute interstitial nephritis as an immune-related adverse event after treatment initiation; however, a good response to steroid therapy was observed. The antitumor effect of the immunotherapy was notable. Although he experienced pulmonary embolism, it seemed asymptomatic and harmless; thus, a second infusion was introduced. From the eighth day, he demonstrated rapidly worsening cardiogenic shock with asymptomatic electrocardiographic changes and drastic drop in cardiac biomarkers, and a diagnosis of myocarditis as an immune-related adverse event was made. Although immediate methylprednisolone mini-pulse therapy followed by tapered prednisolone prevented mortality, extensive myocardial fibrosis with marked ejection fraction decline persisted as a sequela. Consequently, follow-up without treatment was instituted; however, much of the tumor response initially observed was maintained over several months.

CONCLUSION:

Physicians treating patients with immune checkpoint inhibitors should be aware of their potentially life-threatening cardiotoxic effects. This study emphasized the importance of a high index of suspicion, prompt diagnosis, and early intervention in patients who present with cardiac abnormalities and possible myocarditis after receiving immunotherapy.

• Authors: Yasuyuki Miyauchi, Hirohito Naito, Hiroyuki Tsunemori, Ryosuke Tani, Yusuke Hasui, Yuichi Miyake, Tetsuo Minamino, Ryo Ishikawa, Yoshio Kushida, Reiji Haba, Mikio Sugimoto
• Journal: Journal of medical case reports (J Med Case Rep) Vol. 15 Issue 1 Pg. 508 (Oct 15 2021) ISSN: 1752-1947 [Electronic] England
• PMID: 34649593 (Publication Type: Case Reports, Journal Article)
• Copyright: © 2021. The Author(s).

Chemical References

• Antineoplastic Agents, Immunological
• Ipilimumab
• Nivolumab

Topics

• Aged
• Antineoplastic Agents, Immunological (adverse effects)
• Carcinoma, Renal Cell (drug therapy)
• Humans
• Ipilimumab (adverse effects)
• Kidney Neoplasms (drug therapy)
• Male
• Myocarditis (chemically induced)
• Nivolumab (adverse effects)