Severe cardiotoxicity in 2 patients with thymoma receiving immune checkpoint inhibitor therapy: A case report

Immune checkpoint inhibitors (ICIs) are currently approved for a variety of cancers and their use is expanding from advanced disease to first-line metastatic and adjuvant therapies. With the wide application of immunotherapy, its adverse reactions are also the object we need to pay attention to. Among its adverse events, immune myocarditis has low morbidity, but a high fatality rate. Simultaneously, the unique biological properties of thymic epithelial tumors (TETs) increase the risk of immune-mediated toxicity. PATIENT CONCERNS: Patient 1 underwent chest computed tomography (CT) in April 2019 due to physical examination, which showed pleural metastasis of thymoma. Tissue puncture under CT guidance revealed type B2 thymoma. First-line chemotherapy with docetaxel combined with nedaplatin was administered, and apatinib was administered as a maintenance therapy after chemotherapy. After a regular review, progression of the disease was observed in April 12, 2021. Patient 2 underwent anterior mediastinal tumor resection on August 2, 2019, due to the completion of the CT examination during myasthenia gravis to suggest a thymic tumor. Postoperative pathology revealed type B3 thymoma. The patient underwent local radiotherapy from October 2019 to November 2019. After irregular reexamination, the patient’s condition was stable. Disease progression has been observed in June 2021. DIAGNOSIS: Both patients were diagnosed with thymoma. INTERVENTIONS: Patient 1 was administered one cycle of gemcitabine, carboplatin, and sintilimab after disease progression. Patient 2 was treated with docetaxel and cisplatin for 2 cycles, and tislelizumab was added in the second cycle. OUTCOMES: Both patient 1 and patient 2 developed immune myocarditis after one cycle of immunotherapy. The difference was that patient 1 died within a few days. After a few days of active treatment for patient 2, the immune myocarditis did not improve significantly, and the patient chose to give up the treatment and go home. The shocking outcome is that the patient remains alive and stable. LESSONS: Oncologists should be wary of ICI-related myocarditis owing to its early onset, nonspecific symptoms, and fulminant progression, especially when ICIs are used in combination. The patient’s cardiac condition should be assessed before administering ICIs.