Abstract
Immune checkpoint inhibitors (ICI) have constituted a paradigm shift in the management of patients with cancer. Their administration is associated with a new spectrum of immune-related toxicities that can affect any organ. In patients treated with ICI, cardiovascular toxicities, particularly myocarditis, occur with a low incidence (<1%) but with a high fatality rate (30−50%). ICI-related myocarditis has been attributed to an immune infiltration, comprising of T-cells that are positive for CD3+, CD4+, CD8+, and macrophages that are positive for CD68. The diagnosis remains challenging and is made based on clinical syndrome, an electrocardiogram (ECG), biomarker data, and imaging criteria. In most clinical scenarios, endomyocardial biopsy plays a pivotal role in diagnosis, while cardiac magnetic resonance imaging (cMRI) has limitations that should be acknowledged. In this review, we discuss the role of medical imaging in optimizing the management of ICI related myocarditis, including diagnosis, prognostication, and treatment decisions.
Highlights
Immune checkpoint inhibitors (ICIs) have modified the management of patients with cancer and have improved their prognosis and survival for many tumor types including melanoma, lymphoma, kidney, and lung malignancies [1]
In a study of 77 patients with acute myocarditis, ECGs were normal in 32% of the patients, ST elevation was found in 57%, inverted T wave in 9%, and left bundle branch block in 3% [15]
In cancer patients with ICI-related myocarditis, Pradhan showed that 91% of ECGs were found to be abnormal and that there was a broad spectrum of abnormal findings
Summary
Immune checkpoint inhibitors (ICIs) have modified the management of patients with cancer and have improved their prognosis and survival for many tumor types including melanoma, lymphoma, kidney, and lung malignancies [1]. From a mechanistic point of view, ICIs are monoclonal antibodies that antagonize the pathways for programmed cell death receptor 1 (PD‐1), programmed cell death ligand 1 (PD‐L1), cytotoxic T‐lymphocyte–associated protein 4 (CTLA‐4) and could activate the immune system against cancer cells [2,3,4]
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