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Abstract
Immune checkpoint inhibitors (ICIs) are increasingly recognised to effectuate long-lasting therapeutic responses in solid tumours. However, ICI therapy can also result in various immune-related adverse events, such as ICI-associated myocarditis, a rare but serious complication. The clinical spectrum is wide and includes asymptomatic patients and patients with fulminant heart failure, making it challenging to diagnose this condition. Furthermore, the optimal diagnostic algorithm and treatment of ICI-associated myocarditis is unknown. In this review, we describe two cases on both ends of the spectrum and discuss the challenges in recognising, diagnosing and treating ICI-associated myocarditis.
Highlights
Immune checkpoint inhibitors (ICIs) have led to a revolution in the treatment of a variety of cancers
Little is known about the optimal algorithm to screen for and diagnose ICIassociated myocarditis
We provide a review of the literature and discuss the challenges in recognising, diagnosing and treating ICI-associated myocarditis
Summary
Immune checkpoint inhibitors (ICIs) have led to a revolution in the treatment of a variety of cancers. Given the new-onset third-degree AV block, elevated cardiac markers and recent initiation of immunotherapy, ICI-associated myocarditis was suspected. The significant rise in cardiac markers was thought to be related to a flare-up of the ICI-associated myocarditis due to prednisolone tapering. A 70-year-old patient with diabetes mellitus and chronic obstructive pulmonary disease was diagnosed with type 1 metastatic papillary renal cell carcinoma He was included in a randomised phase II study and assigned to treatment with ipilimumab 1 mg/kg and nivolumab 3 mg/kg intravenously, every 3 weeks for four cycles (ClinicalTrials.gov NCT03075423) [6]. Given the continuing rise in cardiac markers, new ECG changes and absence of other explanations, ICI-associated myocarditis was diagnosed, and methylprednisolone was initiated at 500 mg/day intravenously.
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