CD274 and pericardial effusion: In clinically urgent, symptomatic cases with high tumor burden, such as large-volume malignant pleural effusions with lung compression and a pericardial effusion causing tamponade, particularly when PD-L1 expression is high, starting all three agents together may be clinically justified to achieve rapid tumor control while pursuing durability, so long as it is used judiciously with close safety monitoring.