P693Cardiac biomarkers for the detection of anthracycline cardiotoxicity in childhood cancer - a meta-analysis

Introduction

Heart failure is the most concerning cardiovascular side effect of anthracycline chemotherapy. Pediatric cancer patients and survivors of childhood cancer are particularly vulnerable to cancer therapy-related cardiotoxicity. Cardiac biomarkers may be beneficial for screening and diagnosis of anthracycline-related heart failure in pediatric cancer patients and survivors of childhood cancer but systematic data is not yet available.

Purpose

To evaluate (N-terminal pro) brain natriuretic peptide (BNP/NT-proBNP) and cardiac troponin for screening and prediction of cancer therapy-related cardiotoxicity in pediatric cancer patients and survivors of childhood cancer.

Methods

Cochrane, PubMed, Web of Science, and Wiley Library were screened for studies investigating cardiac troponin or BNP/NT-proBNP in pediatric cancer patients receiving anthracycline therapy or survivors of childhood cancer. The primary endpoint was left ventricular (LV) dysfunction as defined by decreased ejection fraction (EF) or fractional shortening (FS). The study was registered at the International prospective register of systematic reviews (PROSPERO) (CRD42018106616).

Results

A total of 1643 subjects from 27 studies were included. BNP/NT-proBNP levels were higher in patients post-treatment compared to control subjects or pre-treatment values (standardized mean difference = 1.0; 95% CI: 0.6–1.4; n=239). The risk for left ventricular (LV) dysfunction was increased in patients with elevated BNP/NT-proBNP (OR=5.5; 95% CI: 2.0–15.2; n=357). This was demonstrated for acute cardiotoxicity (OR=22.3; 95% CI: 3.3–151.1; n=88) and in survivors of childhood cancer (OR=3.2; 95% CI: 1.0–10.0; n=269). Sensitivity for the prediction of acute or subacute LV dysfunction was 28.9% and specificity was at 91.7%. The frequency of troponin elevations was increased after anthracycline therapy (OR=3.6; 95% CI: 2.0–6.5; n=305) but troponin was not associated with LV dysfunction (OR=0.2; 95% CI: −0.2 to 0.5; n=273).

Conclusion

BNP/NT-proBNP is elevated in pediatric patients receiving anthracycline chemotherapy and serves as a marker for the prediction of cardiotoxicity and screening for late cardiotoxicity in survivors of childhood cancer. So far, there is no systematic evidence on a benefit of cardiac troponin for the detection of anthracycline cardiotoxicity in children. Standardized recommendations on the role of cardiac biomarkers are needed for the optimal detection of anthracycline cardiotoxicity in childhood cancer patients.

Acknowledgement/Funding

IFORES research grant of the Medical Faculty, University Duisburg-Essen, Essen, Germany

P683Cardiovascular adverse events associated with BRAF and MEK inhibitors

Background

Cardiovascular adverse events (CVAE) following treatment with B-Raf proto-oncogene serine/threonine kinase inhibitors and mitogen-activated protein kinase (BRAF/MEK) inhibitors in patients with melanoma remain incompletely characterized. We conducted the first detailed meta-analysis focused on BRAF/MEK inhibitor-associated CVAE.

Purpose

To determine the type and risk of BRAF/MEK inhibitor-associated CVAE.

Methods

We systematically searched Pubmed, Cochrane, and Web of Science for keywords “vemurafenib”, “dabrafenib”, “encorafenib”, “trametinib”, “binimetinib”, “cobinimetinib” through November 30, 2018. We selected randomized controlled trails (RCT) reporting on CVAE in melanoma patients under BRAF/MEK inhibitors. The selected endpoints were: decrease in left ventricular ejection fraction (LVEF), pulmonary embolism, atrial fibrillation, arterial hypertension, myocardial infarction, heart failure, pericarditis, and QTc interval prolongation. All-grade and high-grade (grade 3 or higher) CVAE were recorded.

Results

9 RCTs including 4,616 patients with melanoma were selected. The treatment with BRAF/MEK inhibitors was associated with an increased risk in a decrease in LVEF, pulmonary embolism, atrial fibrillation, and arterial hypertension. The relative risks (RR) of myocardial infarction, heart failure, pericarditis, and QTc prolongation were similar between the BRAF/MEK inhibitors group and control group (Figure). These results were consistent for high-grade CVAE. The subgroup analysis showed that the combination therapy with BRAF/MEK inhibitors resulted in a higher risk of a decrease in LVEF, pulmonary embolism, and arterial hypertension, while the risk for atrial fibrillation was increased in BRAF inhibitors monotherapy group compared to controls. There was no significant difference between melanoma patients with mean age below and above 55 years old, except for the increased risk of atrial fibrillation in the older population group. The endpoints were similar between studies with mean follow-up times under and over 24 months.

RR of cardiovascular adverse events

Conclusions

The therapy with BRAF and MEK inhibitors is associated with a higher risk of CVAE. This study increases the awareness on CVAE under these therapies and help to balance between beneficial melanoma treatment options and increased cardiovascular morbidity and mortality.

2416PD1-blocking immune checkpoint inhibitor therapy for malignant melanoma induces left ventricular dysfunction

Background

Immune checkpoint inhibitor therapy has significantly improved treatment of advanced malignant diseases. However, patients receiving immune checkpoint inhibitor therapy with programmed death 1 (PD1) blocking agents are at risk for cardiotoxicity with high mortality. The underlying pathomechanisms have not yet been elucidated.

Purpose

This study aims to evaluate the cardiotoxic effect of PD1-blocking agents and its underlying mechanism with focus on myocardial inflammation and metabolism.

Methods

A transplantable melanoma mouse model was used to study PD1 blocking therapy in a preclinical setting. In brief, mice were subcutaneously transplanted with a melanoma cell line and treated with anti-PD1 antibodies or non-specific immunoglobulin control for 14 days. Murine transthoracic echocardiography including strain analysis was conducted to assess left ventricular (LV) function. Pressure/volume analysis was performed using a micro-tip catheter introduced into the LV via the right commune carotid artery. Inotropic stress was induced by dobutamine. Myocardial immune cell infiltration and expression of PD1/PD-L1 was assessed using flow cytometry. A combined approach for mass spectrometry-guided profiling of proteome, lipids and metabolites was applied to evaluate changes in cardiomyocyte function and metabolism.

Results

Reduced tumor size in anti-PD1-treated animals confirmed response to treatment (n=7; p=0.018). Echocardiographic examination revealed reduced LV ejection fraction (EF) (n=7–8; p=0.001) and reduced global radial strain in anti-PD1-treated mice compared to control littermates (n=3–4; p=0.004). Remarkably, pressure/volume catheterization indicated reduced EF, stroke volume and stroke work under dobutamine stress in anti-PD1-treated mice (p=0.013; n=3–4). Anti-PD1 treatment was associated with a 2-fold elevated level of CD4+ and CD8+ T-cells in murine hearts (n=8; p=0.009 and p=0.049). CD44 expression was upregulated in CD8+ T-cells of anti-PD1-treated animals (n=8; p=0.024). Proteomics revealed downregulation of proteins critical for cardiomyocyte contraction, e.g. ryanodine receptor 2 and L-type calcium channel beta 2 (n=4; p<0.05). Analysis of metabolites and lipids indicated dysfunctional energy metabolism. To identify a potential underlying mechanism, expression of PD1 and its ligand PD-L1 on cardiac cell populations was examined. PD-L1 was mainly expressed on cardiac endothelial cells while PD1 was expressed on 10–20% of murine cardiomyocytes (n=12; p<0.001 and p=0.004).

Conclusion

The obtained results point towards a cardiotoxic effect of PD1 blocking therapy with severely disturbed cardiac function and disrupted cardiomyocyte functional integrity. Myocardial expression of the PD1 receptor could mediate the observed effect. This could potentially promote the development of PD1 immune checkpoint inhibitor-associated myocarditis in patients.

Acknowledgement/Funding

IFORES research grant of the Medical Faculty, University Duisburg-Essen, Essen, Germany

Alcohol use by people in their seventies is not an exception: a preliminary prospective study

The ageing population is rapidly increasing worldwide, and the alcohol-related disease burden in most Western countries is on the rise. However, very few studies assess alcohol use in older people. Here, a self-reported questionnaire was administered to all individuals aged 70 years or more who visited a social centre for older people in western France. The average age of the 98 subjects included in the survey was 79 years (range, 70-97 years; SD=6), and 57.1% (n=56) reported weekly alcohol consumption. An average consumption of over two standard units each day during weekends was reported by 53% subjects (n=52), and the same on each weekday was reported by 34% (n=33). Thus, a significant proportion of subjects aged 70 years or over consumed more alcohol than is recommended in current guidelines. The participants also reported that they rarely discussed alcohol consumption with their general practitioners. Alcohol use should be assessed regularly. District nurses and members of the primary care team should recommend strategies to help older people reduce their alcohol consumption.

Efficacy of an agonist of α-MSH, the palmitoyl tetrapeptide-20, in hair pigmentation

OBJECTIVE

Hair greying (i.e., canities) is a component of chronological ageing and occurs regardless of gender or ethnicity. Canities is directly linked to the loss of melanin and increase in oxidative stress in the hair follicle and shaft. To promote hair pigmentation and reduce the hair greying process, an agonist of α-melanocyte-stimulating hormone (α-MSH), a biomimetic peptide (palmitoyl tetrapeptide-20; PTP20) was developed. The aim of this study was to describe the effects of the designed peptide on hair greying.

METHODS

Effect of the PTP20 on the enzymatic activity of catalase and the production of H₂ O₂ by Human Follicle Dermal Papilla Cells (HFDPC) was evaluated. Influence of PTP20 on the expression of melanocortin receptor-1 (MC1-R) and the production of melanin were investigated. Enzymatic activity of sirtuin 1 (SIRT1) after treatment with PTP20 was also determined. Ex vivo studies using human micro-dissected hairs allowed to visualize the effect of PTP20 on the expression in hair follicle of catalase, TRP-1, TRP-2, Melan-A, ASIP, and MC1-R. These investigations were completed by a clinical study on 15 human male volunteers suffering from premature canities.

RESULTS

The in vitro and ex vivo studies revealed the capacity of the examined PTP20 peptide to enhance the expression of catalase and to decrease (30%) the intracellular level of H₂ O₂ . Moreover, PTP20 was shown to activate in vitro and ex vivo the melanogenesis process. In fact, an increase in the production of melanin was shown to be correlated with elevated expression of MC1-R, TRP-1, and Melan-A, and with the reduction in ASIP expression. A modulation on TRP-2 was also observed. The pivotal role of MC1-R was confirmed on protein expression analysed on volunteer's plucked hairs after 3 months of the daily application of lotion containing 10 ppm of PTP20 peptide.

CONCLUSION

The current findings demonstrate the ability of the biomimetic PTP20 peptide to preserve the function of follicular melanocytes. The present results suggest potential cosmetic application of this newly designed agonist of α-MSH to promote hair pigmentation and thus, reduce the hair greying process.

Inaugural tumor-like multiple sclerosis: clinical presentation and medium-term outcome in 87 patients

BACKGROUND

Tumefactive demyelinating lesions of the central nervous system can be the initial presentation in various pathological entities [multiple sclerosis (the most common), Balo's concentric sclerosis, Schilder's disease and acute disseminated encephalomyelitis] with overlapping clinical presentation. The aim of our study was to better characterize these patients.

METHODS

Eighty-seven patients (62 women and 25 men) from different MS centers in France were studied retrospectively. Inclusion criteria were (1) a first clinical event (2) MRI showing one or more large demyelinating lesions (20 mm or more in diameter) with mass-like features. Patients with a previous demyelinating event (i.e. confirmed multiple sclerosis) were excluded.

RESULTS

Mean age at onset was 26 years. The most common initial symptoms (67% of the patients) were hemiparesis or hemiplegia. Aphasia, headache and cognitive disturbances (i.e. atypical symptoms for demyelinating diseases) were observed in 15, 18 and 15% of patients, respectively. The mean largest diameter of the tumefactive lesions was 26.9 mm, with gadolinium enhancement in 66 patients (81%). Twenty-one patients (24%) had a single tumefactive lesion. During follow-up (median time 5.7 years) 4 patients died, 70 patients improved or remained stable and 12 worsened. 86% of patients received initial corticosteroid treatment, and 73% received disease-modifying therapy subsequently. EDSS at the end of the follow-up was 2.4 ± 2.6 (mean ± SD).

CONCLUSION

This study provides further evidence that the clinical course of MS presenting with large focal tumor-like lesions does not differ from that of classical relapsing-remitting MS, once the noisy first relapsing occurred.

Environmental factors in the development of multiple sclerosis

Epidemiology of Multiple Sclerosis (MS) has been intensively studied and we know now that its occurrence result from the combined action of genetic and environmental factors. There are significant geographic and temporal variations in MS incidence and the risk associated with the development of MS may be affected by many potential factors (including infections, climate, diet, etc.). But none of these factors has been identified as "causal". The accumulation of these different agents as well as their interactions probably contribute to the development of the disease.

Study of gene expression alteration in male androgenetic alopecia: evidence of predominant molecular signalling pathways

BACKGROUND

Male androgenetic alopecia (AGA) is the most common form of hair loss in men. It is characterized by a distinct pattern of progressive hair loss starting from the frontal area and the vertex of the scalp. Although several genetic risk loci have been identified, relevant genes for AGA remain to be defined.

OBJECTIVES

To identify biomarkers associated with AGA.

METHODS

Molecular biomarkers associated with premature AGA were identified through gene expression analysis using cDNA generated from scalp vertex biopsies of hairless or bald men with premature AGA, and healthy volunteers.

RESULTS

This monocentric study reveals that genes encoding mast cell granule enzymes, inflammatory mediators and immunoglobulin-associated immune mediators were significantly overexpressed in AGA. In contrast, underexpressed genes appear to be associated with the Wnt/β-catenin and bone morphogenic protein/transforming growth factor-β signalling pathways. Although involvement of these pathways in hair follicle regeneration is well described, functional interpretation of the transcriptomic data highlights different events that account for their inhibition. In particular, one of these events depends on the dysregulated expression of proopiomelanocortin, as confirmed by polymerase chain reaction and immunohistochemistry. In addition, lower expression of CYP27B1 in patients with AGA supports the notion that changes in vitamin D metabolism contributes to hair loss.

CONCLUSIONS

This study provides compelling evidence for distinct molecular events contributing to alopecia that may pave the way for new therapeutic approaches.

Psychiatric and substance use disorders in HIV/hepatitis C virus (HCV)-coinfected patients: does HCV clearance matter? [Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS) HEPAVIH CO13 cohort]

OBJECTIVES

The objective of this nested study was to assess the prevalence of psychiatric disorders in a sample of HIV/hepatitis C virus (HCV)-coinfected patients according to their HCV status.

METHODS

The nested cross-sectional study, untitled HEPAVIH-Psy survey, was performed in a subset of HIV/HCV-coinfected patients enrolled in the French Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS) CO13 HEPAVIH cohort. Psychiatric disorders were screened for using the Mini International Neuropsychiatric Interview (MINI 5.0.0).

RESULTS

Among the 286 patients enrolled in the study, 68 (24%) had never received HCV treatment, 87 (30%) were treatment nonresponders, 44 (15%) were currently being treated and 87 (30%) had a sustained virological response (SVR). Of the 286 patients enrolled, 121 patients (42%) screened positive for a psychiatric disorder other than suicidality and alcohol/drug abuse/dependence, 40 (14%) screened positive for alcohol abuse/dependence, 50 (18%) screened positive for drug abuse/dependence, 50 (17.5%) were receiving an antidepressant treatment and 69 (24%) were receiving an anxiolytic. Patients with an SVR did not significantly differ from the other groups in terms of psychiatric disorders. Patients receiving HCV treatment screened positive less often for an anxiety disorder. The highest rate of drug dependence/abuse was among HCV treatment-naïve patients.

CONCLUSIONS

Psychiatric disorders were frequent in HIV/HCV-coinfected patients and their rates were comparable between groups, even for patients achieving an SVR. Our results emphasize the need for continuous assessment and care of coinfected patients, even after HCV clearance. Drug addiction remains an obstacle to access to HCV treatment. Despite the recent advent and continued development of directly acting antiviral agents (DAAs), it is still crucial to offer screening and comprehensive care for psychiatric and addictive disorders.