Severe reversible cardiac failure after bortezomib treatment combined with chemotherapy in a non-small cell lung cancer patient: a case report

Abstract

Background: Bortezomib (Velcade), a dipeptide boronate proteasome inhibitor, is a novel anti-cancer agent registered for multiple myeloma (MM). It has also shown promising clinical activity in non-small cell lung cancer (NSCLC). Clinical experience with bortezomib so far indicates that overall incidence of cardiac failure associated with bortezomib therapy remains incidental. Nevertheless, acute development or exacerbation of congestive cardiac failure has been associated with bortezomib treatment.

Case presentation: We present here a case of severe, but reversible, congestive cardiac failure in a lung cancer patient who had no prior cardiac history, after receiving an experimental treatment of bortezomib combined with chemotherapy. Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), as retrospectively measured in archived serum samples, were suggestive of pre-existent (sub-clinical) left ventricular dysfunction.

Conclusion: Based on literature, we hypothesize that baseline presence of sub clinical cardiomyopathy, characterized by a dysregulation of the ubiquitin-proteasome system, could have predisposed this patient for a cardiac side effect induced by systemic proteasome inhibition. Patients with heart disease or risk factors for it should be closely monitored when being submitted to treatment with proteasome inhibition therapy such as bortezomib. Caution is therefore warranted in lung cancer patients who often present with cardiac comorbidities.

Figure 1

Serum levels of NT-proBNP in case report patient," case", and two control patients "control 1"and "control 2". NT-proBNP was measured in case patient at baseline (1389 ng/L), post cycle 2 (2569 ng/L), end-of-treatment (5177 ng/L) and at follow-up (110 ng/L), 10 months after end of treatment. In control patients NT-proBNP was measured at baseline and end-of-treatment only. Baseline NT-proBNP values for control patients 1 and 2 were 117 ng/L and 31 ng/L, end-of-treatment values 31 ng/L and 142 ng/ml respectively. Institutional upper limit of normal is 179 ng/L.