IMMUNE CHECKPOINT INHIBITORS

Presentation and Diagnosis

Tom is an 87-year-old male patient with cardiovascular disease and diabetes who was diagnosed with melanoma of a lesion on his leg. He underwent a wide excision of the area and the margins were clear. He continued follow-up with his oncologist and advanced practitioner, and 3 years after his initial diagnosis, a restaging CT noted a pulmonary nodule. A biopsy of the lung nodule was obtained, which indicated metastatic melanoma.

Treatment

Due to his multiple comorbidities, he was not felt to be a surgical candidate at this time. Tom was started on treatment with nivolumab. Seventeen weeks after beginning therapy, he noted having significant light headedness and nausea, as well as heart palpitations. He went to the local emergency room (ER), and while being evaluated, he went into asystole. 

Cardiovascular Toxicity Mitigation and Management

In the ER, Tom was cardioverted to normal sinus rhythm. Tom’s oncologist felt that the asystole could be associated with the nivolumab and started him on treatment with prednisolone 125 mg/d. The oncologist also obtained a consult with cardiology. Based on the discussion between Tom’s cardiologist and his oncologist, his treatment with nivolumab was discontinued. Since he had no evidence of additional lesions, his healthcare team decided on observation as the next step.