Immunotherapy in recent years has revolutionized the oncology practice. ICIs targeting T lymphocyte antigen-4 (CTLA-4) and programmed death-1/ligand-1 (PD-1/PD-L1) transformed treatment landscape of many different cancers. The answers occur in a substantial fraction of patients and are often durable. ICI's combined block (CB) (CTLA-4 + PD-1/PD-L1) seems to improve even further clinical outcomes compared to monotherapies. However, this treatment exposes patients to the risk of immune adverse events (iAE) including cardiovascular (CV) iAE, which can be potentially fatal and, in any case, compromise the continuation of oncological treatment. Here we present the case of a young woman with advanced renal cancer (Stage IV, T3b, N0, M1) in ICI combined block therapy (Nivolumab + Ipilumab) complicated early by a pericardial effusion (PE)
Oct 2021: a 48 yrs old woman with sarcomatoid and rhabdoid renal cell cancer with liver metastases underwent left radical nephrectomy and splenectomy + cavotomy for neoplastic thrombus removal. Dec 21, she started ICIs CB (Nivolumab + Ipilumab) X 4 and sequential Nivolumab. March 2022: on CT assessment for disease restaging at the end of induction therapy with nivolumab + Ipilumab a favorable response of metastases was detected but incidental finding of G2-G3 PE was identified (figure 1). Therapy with prednisone (1 mg/kg/day) and Colchicine 0.5 mg/day was promptly started with progressive reduction of the effusion in the serial cardiological checks without recurrence although maintenance immunotherapy with Nivolumab was rechallenged. ICIs was permanently discontinued in June 2022 due to gastrointestinal G4 toxicity. At MRI evaluation after 6 months ICIs discontinuation (December 2022), liver metastases were further reduced compared to previous assessments.
This case confirms that the association between iAE side effects and efficacy of ICIs is a real possibility. Vigilant surveillance and close collaboration between oncologists and cardiologists facilitate timely capture of CV iAE and appropriate management to allow effective management.