Curative-intent lung resection after recovery from fulminant immune checkpoint inhibitor-associated myocarditis during neoadjuvant therapy: a case report.

Abstract

Background: Immune checkpoint inhibitor (ICI)-associated myocarditis is a rare but potentially fatal immune-related adverse event (irAE) that may interrupt planned curative treatment for resectable non-small-cell lung cancer. However, the suitability of definitive surgery after recovery from fulminant myocarditis remains unclear.

Case presentation: A 53-year-old man with left upper lobe adenocarcinoma and ipsilateral hilar nodal disease was administered four cycles of neoadjuvant cisplatin, pemetrexed, and pembrolizumab, resulting in a partial response. Eighty-six days after the initiation of neoadjuvant chemoimmunotherapy, he developed grade 4 fulminant ICI-associated myocarditis with ventricular fibrillation and cardiac arrest. Endomyocardial biopsy revealed active lymphocytic myocarditis. The patient required intubation, percutaneous cardiopulmonary support, intra-aortic balloon pumping, continuous hemodiafiltration, high-dose corticosteroids, and prolonged rehabilitation. After his cardiac function recovered, tumor regrowth without distant metastasis was identified. Multidisciplinary reassessment supported surgery because the left ventricular ejection fraction had recovered to 71%, no recurrent malignant arrhythmia had been documented, cardiac biomarkers had improved, prednisolone had been tapered to 10 mg/day, and the disease remained technically resectable. Thoracoscopic-assisted thoracotomy with left upper lobe sleeve resection, pulmonary artery reconstruction, and hilar and mediastinal lymph node dissection was performed 144 days after myocarditis onset, corresponding to 230 days after the initiation of neoadjuvant chemoimmunotherapy. R0 resection was achieved. Surveillance computed tomography showed no evidence of recurrence through 3.5 years after surgery, and the patient was alive at the last follow-up 6.3 years after surgery.

Conclusions: Fulminant ICI-associated myocarditis does not necessarily preclude subsequent curative-intent lung resection. In highly selected patients, surgery may remain feasible after objective cardiac recovery, multidisciplinary reassessment, and shared decision-making with the patient. This case suggests that the acute management of life-threatening cardiovascular irAEs should be undertaken at centers with continuous on-site cardiology support, multidisciplinary care, and access to emergency mechanical circulatory support. Additionally, planning subsequent curative-intent surgery requires multidisciplinary collaboration, ready access to cardiology expertise, and an appropriate pathway for rapid escalation of cardiovascular care.