Myriam Ayari, Sarra Ben Azouz, Meriem Ncir, Rim Bouyahia, Sarra Ben Rejeb, Mehdi Charfi, Taieb Jomni
This case suggests that atezolizumab-bevacizumab rechallenge may be feasible in carefully selected patients with advanced HCC after recovery from non-fulminant ICI-associated myocarditis under close multidisciplinary supervision. It also highlights the importance of histological confirmation in atypical nodal progression during immunotherapy, particularly when imaging findings may be confounded by alternative explanations.
BACKGROUND: atezolizumab-bevacizumab is the standard first-line systemic treatment for unresectable hepatocellular carcinoma (HCC). Immune checkpoint inhibitor (ICI)-associated myocarditis is a rare but potentially life-threatening immune-related adverse event. Evidence regarding ICI rechallenge after myocarditis remains limited, particularly in patients with HCC.
CASE PRESENTATION: We report the case of a 59-year-old man with hepatitis C-related cirrhosis and advanced HCC with portal vein tumor thrombosis, treated with atezolizumab-bevacizumab. After two treatment cycles, he developed non-fulminant ICI-associated myocarditis, characterized by chest pain, elevated cardiac biomarkers, and cardiac magnetic resonance imaging findings consistent with acute myocarditis. Atezolizumab was discontinued, and high-dose corticosteroid therapy was initiated, resulting in complete clinical, biochemical, and radiological recovery. The patient initially achieved a partial tumor response with normalization of alpha-fetoprotein (AFP). During temporary treatment interruption, he subsequently developed radiological disease progression, including enlargement of the hepatic lesion, portal vein tumor thrombosis, and extensive supra- and infradiaphragmatic necrotic lymphadenopathy. Following multidisciplinary evaluation and documented resolution of myocarditis, atezolizumab-bevacizumab rechallenge was undertaken under corticosteroid cover. The patient received six additional cycles with good tolerance, no recurrence of myocarditis, and stable disease on follow-up imaging.
CONCLUSION: This case suggests that atezolizumab-bevacizumab rechallenge may be feasible in carefully selected patients with advanced HCC after recovery from non-fulminant ICI-associated myocarditis under close multidisciplinary supervision. It also highlights the importance of histological confirmation in atypical nodal progression during immunotherapy, particularly when imaging findings may be confounded by alternative explanations.