Fatal Heart Failure After a 26-Month Combination of Tyrosine Kinase Inhibitors in a Papillary Thyroid Cancer

BACKGROUND: Patients with progressive refractory thyroid cancer are potential candidates for clinical trials using tyrosine kinase inhibitors (TKIs), and a promising proportion of patients in these trials have achieved stable disease. Here we report an unusual adverse experience in a patient receiving a combination of TKIs. SUMMARY: The patient was a 62-year-old man with chronic myloid leukemia (CML) and thyroid carcinoma that did not concentrate iodide and had metastases. He was started on imatinib for his CML. About 5 months later he was started on sorafenib for his thyroid cancer. At this time he had no risk factors for cardiac disease except moderate obesity. He had a complete cytogenetic response in his CML, and a partial response in his thyroid cancer. Twenty-one months after starting the combination of TKIs, he manifested signs of coronary artery disease. He received a combination of medications and his TKIs were continued. He died of a sudden myocardial infarction with cardiogenic shock 28 months after starting the combination of TKIs. A retrospective analysis of sequential 18-fludeoxyglucose positron emission tomography scans (18-FDG PET scans) were indicative of cardiac toxicity developing during the period of concomitant administration of TKIs. CONCLUSION: We report the first case of apparent lethal cardiotoxicity with imatinib-sorafenib combined therapy. Combination TKI treatment may enhance the risk of adverse effects. Our experience with this patient suggests that cardiac PET scan should be monitored closely in these type of patients.