Key result
Nivolumab and cabozantinib combination linked to late-onset myocarditis with biventricular dysfunction at ~6 months.
Why the study?
Immune checkpoint inhibitor-induced myocarditis typically occurs early after treatment initiation, but vigilance is needed for delayed presentations in complex oncological settings.
Case Report (n=1)
This case highlights the critical need for prolonged cardiac monitoring during immune checkpoint inhibitor therapy, as delayed-onset myocarditis can present subclinically and requires advanced CMR for accurate diagnosis.
May warrant extended surveillance for delayed ICI-myocarditis; extends reports of late-onset cases but leaves open optimal monitoring strategies.
Introduction Intracardiac metastasis from renal cell carcinoma (RCC) is an infrequent clinical finding. Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but are associated with immune–related adverse events (irAEs). Among these, ICI–induced myocarditis is a rare but potentially fatal complication, typically occurring early after treatment initiation. However, vigilance must be maintained for delayed presentations, especially in complex oncological settings. Case Report A 75–year–old male with a history of hypertension and previous left nephrectomy (2012) for RCC underwent surgical resection of a 38 mm right ventricular (RV) metastasis in early 2024 (Figure 1-2). In April 2025, due to disease progression, he started combination therapy with Nivolumab and Cabozantinib (baseline LVEF 65%).In November 2025, after six months of therapy, routine oncological follow–up revealed a persistent, asymptomatic elevation of cardiac biomarkers (High–Sensitivity Troponin T 19.9 ng/ml, NT–proBNP 345 pg/ml, CK–MB 7.8 ng/ml). Echocardiography showed a significant decline in systolic function (LVEF 45%) and a reduction in RV longitudinal function (TAPSE 11 mm). To confirm the diagnosis and differentiate from post–surgical sequelae, Cardiac Magnetic Resonance (CMR) was performed. CMR quantitative tissue characterization revealed increased native T1 and T2 mapping values, along with a significantly elevated Extracellular Volume (ECV) fraction. Based on these findings, Nivolumab–induced myocarditis was diagnosed. Therapy was promptly interrupted and high–dose corticosteroid treatment was initiated, leading to clinical stabilization and a gradual downward trend of biomarkers. Conclusions This case emphasizes the importance of cardiac monitoring during ICI therapy, even beyond the initial months of treatment. Delayed–onset myocarditis can present subclinically, with subtle biomarker elevations and biventricular dysfunction. A high clinical suspicion and the use of advanced CMR parameters, such as T1/T2 mapping and ECV, are essential for the timely diagnosis and management of this life–threatening irAE, particularly when prior cardiac surgery complicates the clinical picture.Figure 1 Figure 2
No takes yet. Share an insight, caveat, or question.
Mistrulli et al. (2026) conducted a case report in Renal cell carcinoma with right ventricular metastasis and ICI-induced myocarditis (n=1). Nivolumab and Cabozantinib was evaluated. Nivolumab and Cabozantinib combination therapy induced late-onset myocarditis with biventricular dysfunction in a 75-year-old male six months after treatment initiation.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: