https://orcid.org/0000-0002-1786-0176
We present a case of an elderly female with lung cancer who was incidentally found to have myocardial ischaemia in the right and left ventricles (RV and LV) as well as rheumatoid polymyalgia on 18F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT).
In the initial scan, a high FDG uptake (SUVmax = 24.0) was observed in the primary lung lesion (Panels A and B; red arrow). Physiological FDG accumulation in the basal-dominant LV was also observed (Panel C).
The patient was treated with immune checkpoint inhibitors, Ipilimumab and Nivolumab, for recurrence after left lower lobe resection. Follow-up FDG-PET/CT revealed pleural dissemination (Panels D and E; yellow arrow) as well as increased FDG accumulation in the synovia of multiple bilateral joints and muscles (Panels D, F–H), raising suspicion of Nivolumab-induced rheumatoid polymyalgia. Focusing on the myocardium, a localized accumulation appeared in the inferior to inferoseptal LV wall (Panel I; white arrow), and also in the RV wall (Panel I; black arrow). Coronary artery CT (CACT) revealed severe stenosis in the proximal portion of the right coronary artery (RCA), closer to the RV branch (RVB) (Panel J; orange arrow). The superimposition of CACT and PET showed increased accumulation in a wide range of the RCA territory (Panels K–M; white arrows), including the RVB region (Panel K; black arrow). Subsequent coronary angiography confirmed the RCA stenosis (Panels N and O).
Treatment with immune checkpoint inhibitors can lead to serious side effects such as autoimmune diseases and atherosclerotic vascular events, which has become an area of interest in the field of cardio-oncology. FDG-PET/CT is a useful tool for evaluating the active inflammation and myocardial metabolic shift, alongside cancer on a single scan.
Funding: None declared.
Data availability: The datasets used and/or analysed during the current study are available from the corresponding author on request.
Author notes
Conflict of interest: N.O.-M. receives payments for lectures from Bayer Yakuhin, Ltd and Canon Medical Systems.
