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Carboplatin/pembrolizumab/pemetrexed Paraneoplastic pericarditis: case reportA 54-year-old man developed paraneoplastic pericarditis during treatment carboplatin, pemetrexed and pembrolizumab for metastatic non-small cell lung cancer.The man was diagnosed with metastatic non-small cell lung cancer in June 2020. A routine echocardiogram performed during pre-treatment evaluation revealed a left ventricular ejection fraction (LVEF) of 59%, and mild mitral and tricuspidal insufficiency. He started receiving carboplatin AUC5 + pemetrexed 500 mg/mq + pembrolizumab 200mg every 21 days as first-line treatment [routes not stated]. On day 5 of the cycle 1, he presented to the emergency room (ER) with intense chest pain and general malaise. Physical examination demonstrated arrhythmic heartbeat. Electrocardiography detected atrial fibrillation with a high HR, with an ST segment elevation in the low lateral leads. A transthoracic echocardiogram revealed normal LVEF and a 2mm pericardial effusion. Ddimer and CRP levels were elevated. Troponin-I was negative. Lateral ST-elevation myocardial infarction (STEMI) was suspected.Hence, the man was treated with heparin, ticagrelor and metoprolol in combination with pantoprazole and atorvastatin. He was admitted to the coronary care unit. Coronarography revealed no signs of coronary disease. A CT angiography excluded pulmonary thromboembolism. Based on the clinical symptoms, ECG findings and the negative coronarography, he was treated with high doses of unspecified antiplatelet therapy and colchicine. He was admitted for possible pericarditis. Methylprednisolone was added to his ongoing treatment. After 4 days, he was treated with digoxin and amiodarone due to the recurrence of atrial fibrillation. Sinus rhythm was restored. A new echocardiogram revealed an LVEF of 57%, without alterations in cardiac kinetics and circumferential pericardial effusion (6mm + 3mm). One week later, he experienced intense chest pain recurrence upon awakening, which responded to morphine. An urgent echocardiogram revealed a good haemodynamic function, but a worsening pericardial effusion of 8 + 8mm, with no signs of cardiac tamponade. Therefore, the daily dose of methylprednisolone was increased, and cardiac MRI was performed to investigate the aetiology of the pericarditis. His LVEF was stable (55%). Global systolic function was normal. A blood serum pericardial effusion (15mm), comprising several blood clots right upon the right ventricle was noted. Intense oedema was noted both in the parietal and the visceral pericardium. No signs of cardiac tamponade were noted. It was considered to be a moderate paraneoplastic pericarditis, with a prevalent blood component and without any myocardial localisation. During the following days, CRP levels remained elevated and troponin remained negative. He was transitioned from methylprednisolone to prednisone. Subsequently, echocardiogram noted improvement in the pericardial effusion (6mm versus 15mm). He was discharged on tapering steroid scheme and colchicine for 6 mon...
Carboplatin/pembrolizumab/pemetrexed Paraneoplastic pericarditis: case reportA 54-year-old man developed paraneoplastic pericarditis during treatment carboplatin, pemetrexed and pembrolizumab for metastatic non-small cell lung cancer.The man was diagnosed with metastatic non-small cell lung cancer in June 2020. A routine echocardiogram performed during pre-treatment evaluation revealed a left ventricular ejection fraction (LVEF) of 59%, and mild mitral and tricuspidal insufficiency. He started receiving carboplatin AUC5 + pemetrexed 500 mg/mq + pembrolizumab 200mg every 21 days as first-line treatment [routes not stated]. On day 5 of the cycle 1, he presented to the emergency room (ER) with intense chest pain and general malaise. Physical examination demonstrated arrhythmic heartbeat. Electrocardiography detected atrial fibrillation with a high HR, with an ST segment elevation in the low lateral leads. A transthoracic echocardiogram revealed normal LVEF and a 2mm pericardial effusion. Ddimer and CRP levels were elevated. Troponin-I was negative. Lateral ST-elevation myocardial infarction (STEMI) was suspected.Hence, the man was treated with heparin, ticagrelor and metoprolol in combination with pantoprazole and atorvastatin. He was admitted to the coronary care unit. Coronarography revealed no signs of coronary disease. A CT angiography excluded pulmonary thromboembolism. Based on the clinical symptoms, ECG findings and the negative coronarography, he was treated with high doses of unspecified antiplatelet therapy and colchicine. He was admitted for possible pericarditis. Methylprednisolone was added to his ongoing treatment. After 4 days, he was treated with digoxin and amiodarone due to the recurrence of atrial fibrillation. Sinus rhythm was restored. A new echocardiogram revealed an LVEF of 57%, without alterations in cardiac kinetics and circumferential pericardial effusion (6mm + 3mm). One week later, he experienced intense chest pain recurrence upon awakening, which responded to morphine. An urgent echocardiogram revealed a good haemodynamic function, but a worsening pericardial effusion of 8 + 8mm, with no signs of cardiac tamponade. Therefore, the daily dose of methylprednisolone was increased, and cardiac MRI was performed to investigate the aetiology of the pericarditis. His LVEF was stable (55%). Global systolic function was normal. A blood serum pericardial effusion (15mm), comprising several blood clots right upon the right ventricle was noted. Intense oedema was noted both in the parietal and the visceral pericardium. No signs of cardiac tamponade were noted. It was considered to be a moderate paraneoplastic pericarditis, with a prevalent blood component and without any myocardial localisation. During the following days, CRP levels remained elevated and troponin remained negative. He was transitioned from methylprednisolone to prednisone. Subsequently, echocardiogram noted improvement in the pericardial effusion (6mm versus 15mm). He was discharged on tapering steroid scheme and colchicine for 6 mon...
Immune checkpoint inhibitors (ICIs) are an important advancement in the field of cancer treatment, significantly improving the survival of patients with a series of advanced malignancies, like melanoma, non-small cell lung cancer (NSCLC), hepatocellular carcinoma (HCC), renal cell carcinoma (RCC), and Hodgkin lymphoma. ICIs act upon T lymphocytes and antigen-presenting cells, targeting programmed cell death protein 1 (PD1), programmed cell death protein ligand 1 (PD-L1), and cytotoxic T-lymphocyte antigen 4 (CTLA-4), breaking the immune tolerance of the T cells against malignant cells and enhancing the body’s own immune response. A variety of cardiac-adverse effects are associated with ICI-based treatment, including pericarditis, arrhythmias, cardiomyopathy, and acute coronary syndrome, with myocarditis being the most studied due to its often-unexpected onset and severity. Overall, Myocarditis is rare but presents an immune-related adverse event (irAE) that has a high fatality rate. Considering the rising number of oncological patients treated with ICIs and the severity of their potential adverse effects, a good understanding and continuous investigation of cardiac irAEs is of the utmost importance. This systematic review aimed to revise recent publications (between 2016–2022) on ICI-induced cardiac toxicities and highlight the therapeutical approach and evolution in the selected cases.
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