51
|
Vasbinder A, Ismail A, Salem JE, Hayek SS. Role of Biomarkers in the Management of Immune-Checkpoint Inhibitor-Related Myocarditis. Curr Cardiol Rep 2023; 25:959-967. [PMID: 37436648 DOI: 10.1007/s11886-023-01915-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI)-related myocarditis poses a major clinical challenge given its non-specific presentation, rapid progression, and high mortality rate. Here, we review the role of blood-based biomarkers in the clinical management of patients with ICI-related myocarditis. RECENT FINDINGS Myocardial injury, its unique pattern, and the co-occurrence with myositis are defining features of ICI-related myocarditis. Non-cardiac biomarkers, specifically creatinine phosphokinase, precedes the symptomatic presentation and is highly sensitive for diagnosing ICI-related myocarditis, making them useful screening biomarkers. Combined elevations in cardiac troponins and non-cardiac biomarkers improve the confidence of an ICI myocarditis diagnosis. High troponin and creatinine phosphokinase levels are strongly associated with severe outcomes. We propose biomarker-based algorithms for the monitoring and diagnosis of ICI-related myocarditis. Biomarkers, such as cardiac troponins and creatine phosphokinase, can be used in combination in the monitoring, diagnosis, and prognostication of patients with ICI-related myocarditis.
Collapse
Affiliation(s)
- Alexi Vasbinder
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA
| | - Anis Ismail
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA
| | - Joe-Elie Salem
- Department of Pharmacology and Clinical Investigation Centre, Pitié-Salpetriere Hospital, Sorbonne Universite, Paris, France
| | - Salim S Hayek
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA.
| |
Collapse
|
52
|
van Heeswijk RB, Bauer WR, Bönner F, Janjic JM, Mulder WJM, Schreiber LM, Schwitter J, Flögel U. Cardiovascular Molecular Imaging With Fluorine-19 MRI: The Road to the Clinic. Circ Cardiovasc Imaging 2023; 16:e014742. [PMID: 37725674 DOI: 10.1161/circimaging.123.014742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Fluorine-19 (19F) magnetic resonance imaging is a unique quantitative molecular imaging modality that makes use of an injectable fluorine-containing tracer that generates the only visible 19F signal in the body. This hot spot imaging technique has recently been used to characterize a wide array of cardiovascular diseases and seen a broad range of technical improvements. Concurrently, its potential to be translated to the clinical setting is being explored. This review provides an overview of this emerging field and demonstrates its diagnostic potential, which shows promise for clinical translation. We will describe 19F magnetic resonance imaging hardware, pulse sequences, and tracers, followed by an overview of cardiovascular applications. Finally, the challenges on the road to clinical translation are discussed.
Collapse
Affiliation(s)
- Ruud B van Heeswijk
- Department of Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Switzerland (R.B.v.H.)
| | - Wolfgang R Bauer
- Department of Internal Medicine I, Universitätsklinikum Würzburg, Germany (W.R.B.)
| | - Florian Bönner
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of Heinrich Heine University, University Hospital Düsseldorf, Germany (F.B.)
| | - Jelena M Janjic
- Graduate School of Pharmaceutical Sciences, School of Pharmacy, Duquesne University, Pittsburgh, PA (J.M.J.)
| | - Willem J M Mulder
- Laboratory of Chemical Biology, Department of Biochemical Engineering, Eindhoven University of Technology, the Netherlands (W.J.M.M.)
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands (W.J.M.M.)
| | - Laura M Schreiber
- Chair of Molecular and Cellular Imaging, Comprehensive Heart Failure Center (CHFC), Wuerzburg University Hospitals, Germany (L.M.S.)
| | - Juerg Schwitter
- Division of Cardiology, Cardiovascular Department (J.S.), Lausanne University Hospital (CHUV), Switzerland
- CMR Center (J.S.), Lausanne University Hospital (CHUV), Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Switzerland (J.S.)
| | - Ulrich Flögel
- Experimental Cardiovascular Imaging (U.F.), Heinrich Heine University, Germany
- Cardiovascular Research Institute Düsseldorf (CARID) (U.F.), Heinrich Heine University, Germany
| |
Collapse
|
53
|
Raschi E, Rossi S, De Giglio A, Fusaroli M, Burgazzi F, Rinaldi R, Potena L. Cardiovascular Toxicity of Immune Checkpoint Inhibitors: A Guide for Clinicians. Drug Saf 2023; 46:819-833. [PMID: 37341925 PMCID: PMC10442274 DOI: 10.1007/s40264-023-01320-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/22/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment and care of patients with cancer owing to unique features, including the occurrence of the so-called immune-related adverse events (irAEs). A multidisciplinary team, possibly including a cardio-oncology specialist, is warranted to achieve a favorable patient outcome. Cardiovascular toxicity, especially myocarditis, emerged as a life-threatening irAE in the real-word setting, and the European Society of Cardiology has recently published the first guideline on cardio-oncology to increase awareness and promote a standardized approach to tackle this complex multimodal issue, including diagnostic challenges, assessment, treatment, and surveillance of patients with cancer receiving ICIs. In this article, through a question & answer format made up of case vignettes, we offer a clinically oriented overview on the latest advancements of ICI-related cardiovascular toxicity, focusing on myocarditis and associated irAEs (myositis and myasthenia gravis within the so-called overlap syndrome), with the purpose of assisting clinicians and healthcare professionals in daily clinical practice.
Collapse
Affiliation(s)
- Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy.
| | - Simone Rossi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Andrea De Giglio
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Michele Fusaroli
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Flavio Burgazzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luciano Potena
- Unit of Heart Failure and Transplantation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| |
Collapse
|
54
|
Chitsazan M, Amin A, Ladel L, Baig A, Chitsazan M. Cardiovascular Toxicity Associated With Immune Checkpoint Inhibitor Therapy: A Comprehensive Review. Crit Pathw Cardiol 2023; 22:69-82. [PMID: 37363862 DOI: 10.1097/hpc.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Immune checkpoint inhibitors (ICIs), a significant breakthrough treatment of cancer, exert their function through enhancing the immune system's ability to recognize and attack cancer cells. However, these revolutionary cancer treatments have been associated with a range of immune-related adverse effects, including cardiovascular toxicity. The most commonly reported cardiovascular toxicities associated with ICIs are myocarditis, pericarditis, arrhythmias, and vasculitis. These cardiovascular manifestations are often severe and can lead to life-threatening complications. Therefore, prompt identification and management of these toxicities is critical, and a multidisciplinary teamwork by cardiologists and oncologists are required to ensure optimal patient outcomes. In this review, we summarize the current knowledge on the mechanisms underlying ICI-associated cardiovascular toxicity, clinical presentations of these toxicities, potential risk factors, diagnosis, management, and surveillance strategies during ICI therapy. While ICIs have already transformed cancer treatment, further research is needed to better understand and manage their immune-related cardiovascular effects, and possibly, to identify biomarkers which can predict the occurrence of these cardiovascular complications.
Collapse
Affiliation(s)
| | - Ahmad Amin
- Medstar Union Memorial Hospital, Baltimore, MD
| | - Luisa Ladel
- From the Department of Medicine, Norwalk Hospital, Norwalk, CT
| | - Alyza Baig
- From the Department of Medicine, Norwalk Hospital, Norwalk, CT
| | - Mitra Chitsazan
- Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
55
|
He W, Zhou L, Xu K, Li H, Wang JJ, Chen C, Wang D. Immunopathogenesis and immunomodulatory therapy for myocarditis. SCIENCE CHINA. LIFE SCIENCES 2023; 66:2112-2137. [PMID: 37002488 PMCID: PMC10066028 DOI: 10.1007/s11427-022-2273-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/16/2023] [Indexed: 04/03/2023]
Abstract
Myocarditis is an inflammatory cardiac disease characterized by the destruction of myocardial cells, infiltration of interstitial inflammatory cells, and fibrosis, and is becoming a major public health concern. The aetiology of myocarditis continues to broaden as new pathogens and drugs emerge. The relationship between immune checkpoint inhibitors, severe acute respiratory syndrome coronavirus 2, vaccines against coronavirus disease-2019, and myocarditis has attracted increased attention. Immunopathological processes play an important role in the different phases of myocarditis, affecting disease occurrence, development, and prognosis. Excessive immune activation can induce severe myocardial injury and lead to fulminant myocarditis, whereas chronic inflammation can lead to cardiac remodelling and inflammatory dilated cardiomyopathy. The use of immunosuppressive treatments, particularly cytotoxic agents, for myocarditis, remains controversial. While reasonable and effective immunomodulatory therapy is the general trend. This review focuses on the current understanding of the aetiology and immunopathogenesis of myocarditis and offers new perspectives on immunomodulatory therapies.
Collapse
Affiliation(s)
- Wu He
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Ling Zhou
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Ke Xu
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Huihui Li
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - James Jiqi Wang
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China.
| | - DaoWen Wang
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China.
| |
Collapse
|
56
|
Gong J, Neilan TG, Zlotoff DA. Mediators and mechanisms of immune checkpoint inhibitor-associated myocarditis: Insights from mouse and human. Immunol Rev 2023; 318:70-80. [PMID: 37449556 PMCID: PMC10528547 DOI: 10.1111/imr.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
The broad application of immune checkpoint inhibitors (ICIs) has led to significant gains in cancer outcomes. By abrogating inhibitory signals, ICIs promote T cell targeting of cancer cells but can frequently trigger autoimmune manifestations, termed immune-related adverse events (irAEs), affecting essentially any organ system. Among cardiovascular irAEs, immune-related myocarditis (irMyocarditis) is the most described and carries the highest morbidity. The currently recommended treatment for irMyocarditis is potent immunosuppression with corticosteroids and other agents, but this has limited evidence basis. The cellular pathophysiology of irMyocarditis remains poorly understood, though mouse models and human data have both implicated effector CD8+ T cells, some of which are specific for the cardiomyocyte protein α-myosin. While the driving molecular signals and transcriptional programs are not well defined, the involvement of chemokine receptors such as CCR5 and CXCR3 has been proposed. Fundamental questions regarding why only approximately 1% of ICI recipients develop irMyocarditis and why irMyocarditis carries a much worse prognosis than other forms of lymphocytic myocarditis remain unanswered. Further work in both murine systems and with human samples are needed to identify better tools for diagnosis, risk-stratification, and treatment.
Collapse
Affiliation(s)
- Jingyi Gong
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Daniel A. Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
57
|
Marquet Y, Hékimian G, Lebreton G, Kerneis M, Rouvier P, Bay P, Mathian A, Bréchot N, Chommeloux J, Petit M, Gautier M, Lefevre L, Saura O, Levy D, Quentric P, Moyon Q, Ortuno S, Schmidt M, Leprince P, Luyt CE, Combes A, Pineton de Chambrun M. Diagnostic yield, safety and therapeutic consequences of myocardial biopsy in clinically suspected fulminant myocarditis unweanable from mechanical circulatory support. Ann Intensive Care 2023; 13:78. [PMID: 37653258 PMCID: PMC10471530 DOI: 10.1186/s13613-023-01169-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 08/03/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Fulminant myocarditis is a rare and severe disease whose definite and etiological diagnoses rely on pathological examination. Albeit, myocardial biopsy can be associated with significant morbidity and mortality, its therapeutic consequences are unclear. We conducted a study to determine the diagnostic yield, the safety and the therapeutic consequences of myocardial biopsy in patients with fulminant clinically suspected myocarditis unweanable from mechanical circulatory support (MCS). METHODS Monocenter, retrospective, observational cohort study in a 26-bed French tertiary ICU between January 2002 and February 2019. Inclusion of all fulminant clinically suspected myocarditis patients undergoing in-ICU myocardial biopsy while being on MCS. The primary endpoint was the proportion of patients classified as definite myocarditis using Bonaca criteria before and after including myocardial biopsy results. RESULTS Forty-seven patients (median age 41 [30-47], female 53%) were included: 55% died before hospital discharge, 34% could be bridged-to-recovery and 15% bridged-to-transplant. Myocardial biopsy was endomyocardial or surgical in 36% and 64% cases respectively. Tamponade requiring emergency pericardiocentesis occurred in 29% patients after endomyocardial biopsy. After adding the biopsy results in the Bonaca classification algorithm the percentage of definite myocarditis raised from 13 to 55% (p < 0.0001). The rate of biopsy-related treatments modifications was 13%, leading to patients' recovery in only 4% patients. CONCLUSIONS In clinically suspected myocarditis unweanable from MCS, myocardial biopsy increased the rate of definite myocarditis but was associated with a low rate of treatment modification and a significant proportion of adverse events. We believe the benefit/risk ratio of myocardial biopsy should be more carefully weighted in these frail and selected patients than suggested by actual guidelines. Further prospective studies are now needed to determine its value in patients under MCS.
Collapse
Affiliation(s)
- Yann Marquet
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Guillaume Hékimian
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Guillaume Lebreton
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- Service de Chirurgie Cardio-Thoracique, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Paris, France
| | - Mathieu Kerneis
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- ACTION Study Group, Département de Cardiologie, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Philippe Rouvier
- Service d'Anatomopathologie, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Pierre Bay
- AP-HP, Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation and UPEC (Université Paris Est), INSERM, Unité U955, Équipe 18, 94010, Créteil, France
| | - Alexis Mathian
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut E3M, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Juliette Chommeloux
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Matthieu Petit
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Melchior Gautier
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Lucie Lefevre
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Ouriel Saura
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - David Levy
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Paul Quentric
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut E3M, Paris, France
- Sorbonne Université, Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Quentin Moyon
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut E3M, Paris, France
| | - Sofia Ortuno
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Pascal Leprince
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- Service de Chirurgie Cardio-Thoracique, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Paris, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France.
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France.
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut E3M, Paris, France.
- Sorbonne Université, Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France.
| |
Collapse
|
58
|
Mikail N, Chequer R, Imperiale A, Meisel A, Bengs S, Portmann A, Gimelli A, Buechel RR, Gebhard C, Rossi A. Tales from the future-nuclear cardio-oncology, from prediction to diagnosis and monitoring. Eur Heart J Cardiovasc Imaging 2023; 24:1129-1145. [PMID: 37467476 PMCID: PMC10501471 DOI: 10.1093/ehjci/jead168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023] Open
Abstract
Cancer and cardiovascular diseases (CVD) often share common risk factors, and patients with CVD who develop cancer are at high risk of experiencing major adverse cardiovascular events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced non-invasive cardiac imaging has raised great interest in the early detection of CVD and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer-treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments and discuss the specific role of nuclear cardiology alongside other non-invasive imaging techniques.
Collapse
Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Renata Chequer
- Department of Nuclear Medicine, Bichat University Hospital, AP-HP, University Diderot, 75018 Paris, France
| | - Alessio Imperiale
- Nuclear Medicine, Institut de Cancérologie de Strasbourg Europe (ICANS), University Hospitals of Strasbourg, 67093 Strasbourg, France
- Molecular Imaging-DRHIM, IPHC, UMR 7178, CNRS/Unistra, 67093 Strasbourg, France
| | - Alexander Meisel
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Kantonsspital Glarus, Burgstrasse 99, 8750 Glarus, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Alessia Gimelli
- Imaging Department, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124 Pisa, Italy
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
- Department of Cardiology, University Hospital Inselspital Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| |
Collapse
|
59
|
De Camilli A, Fischer G. Novel Cellular and Immunotherapy: Toxicities and Perioperative Implications. Curr Oncol 2023; 30:7638-7653. [PMID: 37623035 PMCID: PMC10453139 DOI: 10.3390/curroncol30080554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 08/26/2023] Open
Abstract
Targeted cellular and immunotherapies have welcomed a new chapter in multi-modal cancer therapy. These agents harness our innate immune system and destroy malignant cells in a precise way as compared with "legacy" chemotherapeutic agents that largely rely on abolishing cell division. New therapies can augment the T-cell recognition of tumor antigens and effectively prevent tumor cells from their historically successful ability to evade immune recognition. These novel agents cause acute and chronic toxicities to a variety of organ systems (enteritis, pneumonitis, hypophysitis, and hepatitis), and this may masquerade as other chronic illnesses or paraneoplastic effects. As the perioperative footprint of cancer patients increases, it is essential that perioperative providers-anesthesiologists, surgeons, nurse anesthetists, and inpatient hospital medicine providers-be up to date on the physiologic mechanisms that underlie these new therapies as well as their acute and subacute toxicity profiles. Immunotherapy toxicity can significantly impact perioperative morbidity as well as influence perioperative management, such as prophylaxis for adrenal insufficiency, preoperative pulmonary assessment, and screening for thyroid dysfunction, among others.
Collapse
Affiliation(s)
| | - Gregory Fischer
- Memorial Sloan Kettering, 1275 York Avenue, New York, NY 10065, USA
| |
Collapse
|
60
|
Lehmann LH, Heckmann MB, Bailly G, Finke D, Procureur A, Power JR, Stein F, Bretagne M, Ederhy S, Fenioux C, Hamwy O, Funck-Brentano E, Romano E, Pieroni L, Münster J, Allenbach Y, Anquetil C, Leonard-Louis S, Palaskas NL, Hayek SS, Katus HA, Giannitsis E, Frey N, Kaya Z, Moslehi J, Prifti E, Salem JE. Cardiomuscular Biomarkers in the Diagnosis and Prognostication of Immune Checkpoint Inhibitor Myocarditis. Circulation 2023; 148:473-486. [PMID: 37317858 PMCID: PMC10527069 DOI: 10.1161/circulationaha.123.062405] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/19/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are approved for multiple cancers but can result in ICI-associated myocarditis, an infrequent but life-threatening condition. Elevations in cardiac biomarkers, specifically troponin-I (cTnI), troponin-T (cTnT), and creatine kinase (CK), are used for diagnosis. However, the association between temporal elevations of these biomarkers with disease trajectory and outcomes has not been established. METHODS We analyzed the diagnostic accuracy and prognostic performances of cTnI, cTnT, and CK in patients with ICI myocarditis (n=60) through 1-year follow-up in 2 cardio-oncology units (APHP Sorbonne, Paris, France and Heidelberg, Germany). A total of 1751 (1 cTnT assay type), 920 (4 cTnI assay types), and 1191 CK sampling time points were available. Major adverse cardiomyotoxic events (MACE) were defined as heart failure, ventricular arrhythmia, atrioventricular or sinus block requiring pacemaker, respiratory muscle failure requiring mechanical ventilation, and sudden cardiac death. Diagnostic performance of cTnI and cTnT was also assessed in an international ICI myocarditis registry. RESULTS Within 72 hours of admission, cTnT, cTnI, and CK were increased compared with upper reference limits (URLs) in 56 of 57 (98%), 37 of 42 ([88%] P=0.03 versus cTnT), and 43 of 57 ([75%] P<0.001 versus cTnT), respectively. This increased rate of positivity for cTnT (93%) versus cTnI ([64%] P<0.001) on admission was confirmed in 87 independent cases from an international registry. In the Franco-German cohort, 24 of 60 (40%) patients developed ≥1 MACE (total, 52; median time to first MACE, 5 [interquartile range, 2-16] days). The highest value of cTnT:URL within the first 72 hours of admission performed best in terms of association with MACE within 90 days (area under the curve, 0.84) than CK:URL (area under the curve, 0.70). A cTnT:URL ≥32 within 72 hours of admission was the best cut-off associated with MACE within 90 days (hazard ratio, 11.1 [95% CI, 3.2-38.0]; P<0.001), after adjustment for age and sex. cTnT was increased in all patients within 72 hours of the first MACE (23 of 23 [100%]), whereas cTnI and CK values were less than the URL in 2 of 19 (11%) and 6 of 22 (27%) of patients (P<0.001), respectively. CONCLUSIONS cTnT is associated with MACE and is sensitive for diagnosis and surveillance in patients with ICI myocarditis. A cTnT:URL ratio <32 within 72 hours of diagnosis is associated with a subgroup at low risk for MACE. Potential differences in diagnostic and prognostic performances between cTnT and cTnI as a function of the assays used deserve further evaluation in ICI myocarditis.
Collapse
Affiliation(s)
- Lorenz H. Lehmann
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Markus B. Heckmann
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Guillaume Bailly
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Daniel Finke
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Adrien Procureur
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - John R. Power
- University of California San Diego, San Diego, California, USA
| | - Frederic Stein
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Marie Bretagne
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Stephane Ederhy
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris,, INSERM, Department of Cardiology, CIC-1901, UNICO-GRECO Cardio-oncology program, Saint-Antoine Hospital, Paris, France
| | - Charlotte Fenioux
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Omar Hamwy
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | | | - Emanuela Romano
- Center for Cancer Immunotherapy, Department of Oncology, PSL Research University, Institut Curie, Paris, France
| | - Laurence Pieroni
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Biochimie- Hormonologie, Hôpital Tenon, Paris, France
| | - Jan Münster
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Yves Allenbach
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of internal medecine, Hôpital Pitié-Salpêtrière, Paris, France
| | - Céline Anquetil
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of internal medecine, Hôpital Pitié-Salpêtrière, Paris, France
| | - Sarah Leonard-Louis
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Neuropathology, Hôpital Pitié-Salpêtrière, F-75013 Paris, France
| | - Nicolas L. Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | | | - Salim S. Hayek
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI
| | - Hugo A. Katus
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Ziya Kaya
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Javid Moslehi
- Section of Cardio-Oncology & Immunology, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Edi Prifti
- IRD, Sorbonne University, UMMISCO, 32 Avenue Henri Varagnat, F-93143 Bondy, France; Sorbonne Université, INSERM (NutriOmics), Paris, France
| | - Joe-Elie Salem
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| |
Collapse
|
61
|
Turker I, Johnson DB. Immune checkpoint inhibitor-related myocarditis: current understanding and potential diagnostic and therapeutic strategies. Expert Opin Drug Saf 2023; 22:909-919. [PMID: 37647330 PMCID: PMC10530188 DOI: 10.1080/14740338.2023.2254218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/31/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Myocarditis associated with immune checkpoint inhibitors presents with an often-severe clinical phenotype with arrhythmias and concurrent myositis. This condition tends to occur early after treatment onset and is associated with a high fatality rate. Diagnosis may be challenging, and treatment algorithms are still evolving. AREAS COVERED This review will provide an overview of immune checkpoint inhibitor mechanism of action and how it relates to myocarditis pathophysiology, diagnostic algorithms and potential pitfalls, and emerging treatment approaches published until May 2023. We will focus on the state of the field and potential new directions in research and patient care. We will also provide consensus-based diagnostic and therapeutic algorithms endorsed by major societies. EXPERT OPINION The field needs more evidence-based approaches to risk stratification so that therapy can be tailored toward less cardiotoxic alternatives in high-risk patients. For diagnostic and therapeutic approaches, data from animal models are unlikely to provide conclusive evidence given the complexity of the human immune system. We strongly invite practitioners in the field to contribute every case to the ongoing multicenter registries.
Collapse
Affiliation(s)
- Isik Turker
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, Missouri, MO, USA
| | - Douglas B. Johnson
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
62
|
Matsumori A. Myocarditis and Autoimmunity. Expert Rev Cardiovasc Ther 2023. [PMID: 37243585 DOI: 10.1080/14779072.2023.2219895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/20/2023] [Accepted: 05/26/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Autoimmune myocarditis may develop due to heterogeneous causes. Myocarditis is often caused by viral infections, but it can also be caused by systemic autoimmune diseases. Immune checkpoint inhibitors and virus vaccines induce immune activation, and they can cause the development of myocarditis, as well as several immune-related adverse events. The development of myocarditis is dependent on the genetic factors of the host, and the major histocompatibility complex (MHC) may be an important determinant of the type and severity of the disease. However, non-MHC immunoregulatory genes may also play a role in determining susceptibility. AREA COVERED This review summarizes the current knowledge of the etiology, pathogenesis, diagnosis and treatment of autoimmune myocarditis with a particular focus on viral infection and autoimmunity, and biomarkers of myocarditis. EXPERT OPINION An endomyocardial biopsy may not be the gold standard for the diagnosis of myocarditis. Cardiac magnetic resonance imaging is useful in diagnosing autoimmune myocarditis. Recently identified biomarkers of inflammation and myocyte injury are promising for the diagnosis of myocarditis when measured simultaneously. Future treatments should focus on the appropriate diagnosis of the etiologic agent, as well as on the specific stage of the evolution of immune and inflammatory processes.
Collapse
Affiliation(s)
- Akira Matsumori
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| |
Collapse
|
63
|
Kersten J. Cardiovascular magnetic resonance imaging in COVID-19 patients: An important tool in everyday clinical practice. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:622-623. [PMID: 36706020 DOI: 10.1002/jcu.23415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 05/03/2023]
Affiliation(s)
- Johannes Kersten
- Division of Sports and Rehabilitation Medicine, University Hospital of Ulm, Ulm, Germany
| |
Collapse
|
64
|
Chen YC, Jaffer M, Zhou L, Moslehi J, Forsyth PA, Fecher LA. A Brain, A Heart, and the Courage: Balancing Benefit and Toxicity of Immunotherapy in Melanoma. Am Soc Clin Oncol Educ Book 2023; 43:e390594. [PMID: 37229626 DOI: 10.1200/edbk_390594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The overall survival of advanced melanoma has improved dramatically. Immunotherapies, specifically checkpoint inhibitors, have played a large role in this improvement. These agents have also shown benefit in the adjuvant setting, are approved for treatment of resected stage II, III, and IV melanoma, and play an evolving role in the neoadjuvant setting. Although generally well tolerated, immune-related adverse events occur and can be severe. Here we focus on some severe and potentially long term toxicities, including cardiovascular and neurologic toxicities. Our understanding of the acute and long-term toxicities of immune checkpoint inhibitors continues to evolve. Oncologists must continue to balance cancer risk and treatment-related toxicities.
Collapse
Affiliation(s)
- Yen-Chou Chen
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
- Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Muhammad Jaffer
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
| | - Lylybell Zhou
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Javid Moslehi
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Peter A Forsyth
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
- Department of Oncology, Moffitt Cancer Center and University of South Florida, Tampa, FL
| | - Leslie A Fecher
- Rogel Cancer Center at the University of Michigan, Ann Arbor, MI
| |
Collapse
|
65
|
Coustal C, Vanoverschelde J, Quantin X, Lesage C, Michot JM, Lappara A, Ederhy S, Assenat E, Faure M, Issa N, Lambotte O, Puyade M, Dereure O, Tosi D, Rullier P, Serre I, Larcher R, Klouche K, Chanques G, Vernhet-Kovacsik H, Faillie JL, Agullo A, Roubille F, Guilpain P, Maria ATJ. Prognosis of immune checkpoint inhibitors-induced myocarditis: a case series. J Immunother Cancer 2023; 11:jitc-2022-004792. [PMID: 37258037 DOI: 10.1136/jitc-2022-004792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) have transformed cancer treatment over the last decade. Alongside this therapeutic improvement, a new variety of side effects has emerged, called immune-related adverse events (irAEs), potentially affecting any organ. Among these irAEs, myocarditis is rare but life-threatening. METHODS We conducted a multicenter cross-sectional retrospective study with the aim of better characterizing ICI-related myocarditis. Myocarditis diagnosis was based on the recent consensus statement of the International Cardio-Oncology Society. RESULTS Twenty-nine patients were identified, from six different referral centers. Most patients (55%) were treated using anti-programmed-death 1, rather than ICI combination (35%) or anti-programmed-death-ligand 1 (10%). Transthoracic echocardiography was abnormal in 52% of them, and cardiac magnetic resonance showed abnormal features in 14/24 patients (58%). Eleven patients (38%) were classified as severe. Compared with other patients, they had more frequently pre-existing systemic autoimmune disease (45% vs 6%, p=0.018), higher troponin level on admission (42-fold the upper limit vs 3.55-fold, p=0.001), and exhibited anti-acetylcholine receptor autoantibodies (p=0.001). Seven patients (24%) had myocarditis-related death, and eight more patients died from cancer progression during follow-up. Twenty-eight patients received glucocorticoids, 10 underwent plasma exchanges, 8 received intravenous immunoglobulins, and 5 other immunosuppressants. ICI rechallenge was performed in six patients, with only one myocarditis relapse. DISCUSSION The management of ICI-related myocarditis may be challenging and requires a multidisciplinary approach. Prognostic features are herein described and may help to allow ICI rechallenge for some patients with smoldering presentation, after an accurate evaluation of benefit-risk balance.
Collapse
Affiliation(s)
- Cyrille Coustal
- Department of Internal Medicine, CHRU de Montpellier, Montpellier, France
| | | | - Xavier Quantin
- Department of thoracic oncology, Regional Cancer Centre Val d'Aurelle - Paul Lamarque, Montpellier, France
| | - Candice Lesage
- Department of Dermatology, CHRU de Montpellier, Montpellier, France
| | | | | | - Stephane Ederhy
- Cardiology, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Eric Assenat
- Department of Oncology, CHRU de Montpellier, Montpellier, France
| | - Maxime Faure
- Department of Interventional Cardiology, CHU de Bordeaux Hôpital Cardiologique, Pessac, France
| | - Nahema Issa
- Intensive Care Unit, CHU de Bordeaux, Bordeaux, France
| | - Olivier Lambotte
- Department of Internal Medicine, CHU Bicêtre, Le Kremlin-Bicetre, France
| | - Mathieu Puyade
- Medecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- CIC-1402, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Olivier Dereure
- Department of Dermatology, CHRU de Montpellier, Montpellier, France
| | - Diego Tosi
- Medical Oncology Department, Institut régional du Cancer de Montpellier, Montpellier, France
| | - Patricia Rullier
- Department of Internal Medicine, CHRU de Montpellier, Montpellier, France
| | - Isabelle Serre
- Department of Pathology, CHRU de Montpellier, Montpellier, France
| | - Romaric Larcher
- Department of Intensive Care Medicine, CHRU de Montpellier, Montpellier, France
| | - Kada Klouche
- Department of Intensive Care Medicine, CHRU de Montpellier, Montpellier, France
| | - Gérald Chanques
- Department of Anesthesiology and Critical Care Medicine, CHRU de Montpellier, Montpellier, France
| | | | - Jean-Luc Faillie
- Department of Medical Pharmacology and Toxicology, University Hospital Centre Montpellier, Montpellier, France
| | - Audrey Agullo
- Department of Cardiology, CHRU de Montpellier, Montpellier, France
| | | | - Philippe Guilpain
- Department of Internal Medicine, CHRU de Montpellier, Montpellier, France
- U1183, Institut national de la santé et de la recherche médicale, Paris, France
| | - Alexandre Thibault Jacques Maria
- Department of Internal Medicine, CHRU de Montpellier, Montpellier, France
- U1183, Institut national de la santé et de la recherche médicale, Paris, France
| |
Collapse
|
66
|
Delombaerde D, De Sutter J, Croes L, Vervloet D, Moerman V, Van de Veire N, Willems AM, Wouters K, Peeters M, Prenen H, Vulsteke C. Extensive CArdioVAscular Characterization and Follow-Up of Patients Receiving Immune Checkpoint Inhibitors: A Prospective Multicenter Study. Pharmaceuticals (Basel) 2023; 16:ph16040625. [PMID: 37111382 PMCID: PMC10142365 DOI: 10.3390/ph16040625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The increasing use of immune checkpoint inhibitors (ICIs) in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in the incidence of cardiovascular (CV) immune-related adverse events (irAEs). The current follow-up guidelines are based on anecdotal evidence and expert opinions, due to a lack of solid data and prospective studies. As many questions remain unanswered, cardiac monitoring, in patients receiving ICIs, is not always implemented by oncologists. Hence, an urgent need to investigate the possible short- and long-term CV effects of ICIs, as ICI approval is continuing to expand to the (neo)adjuvant setting. METHODS We have initiated a prospective, multicenter study, i.e., the CAVACI trial, in which a minimum of 276 patients with a solid tumor, eligible for ICI treatment, will be enrolled. The study consists of routine investigations of blood parameters (troponin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, in particular) and a thorough CV follow-up (electrocardiograms, transthoracic echocardiograms, and coronary calcium scoring) at fixed time points for a total period of two years. The primary endpoint is the cumulative incidence of troponin elevation in the first three months of ICI treatment, compared to baseline levels. Furthermore, secondary endpoints include incidence above the upper limit of normal of both troponin and NT-proBNP levels, evolution in troponin and NT-proBNP levels, the incidence of CV abnormalities/major adverse cardiac events, evaluation of associations between patient characteristics/biochemical parameters and CV events, transthoracic echocardiography parameters, electrocardiography parameters, and progression of coronary atherosclerosis. Recruitment of patients started in January 2022. Enrolment is ongoing in AZ Maria Middelares, Antwerp University Hospital, AZ Sint-Vincentius Deinze, and AZ Sint-Elisabeth Zottegem. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05699915, registered 26 January 2023.
Collapse
Affiliation(s)
- Danielle Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | - Johan De Sutter
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | - Lieselot Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | | | | | - Nico Van de Veire
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Department of Cardiology, Free University Brussels, 1000 Brussels, Belgium
| | | | - Kristien Wouters
- Antwerp University Hospital, Clinical Trial Center (CTC), CRC Antwerp, 2650 Edegem, Belgium
| | - Marc Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Hans Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Christof Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| |
Collapse
|
67
|
Toffart AC, Meert AP, Wallet F, Gibelin A, Guisset O, Gonzalez F, Seguin A, Kouatchet A, Delaunay M, Debieuvre D, Duchemann B, Rousseau-Bussac G, Nyunga M, Grimaldi D, Levrat A, Azoulay E, Lemiale V. ICU admission for solid cancer patients treated with immune checkpoint inhibitors. Ann Intensive Care 2023; 13:29. [PMID: 37072645 PMCID: PMC10113402 DOI: 10.1186/s13613-023-01122-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 03/24/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) have revolutionized the management of cancer. They can induce immune-related adverse events (irAE) leading to intensive care unit (ICU) admission. We aimed to describe irAEs for ICU admissions in solid cancer patients treated with ICIs. METHODS This prospective multicenter study was conducted in France and Belgium. Adult patients with solid tumor and treated with systemic ICIs within the last 6 months, requiring non-programmed ICU admission were included. Patients admitted for microbiologically documented sepsis were excluded. Imputability of irAEs in ICU admissions was described according to the WHO-UMC classification system at ICU admission and at ICU discharge. The use of immunosuppressant treatment was reported. RESULTS 115 patients were eligible. Solid tumor was mainly lung cancer (n = 76, 66%) and melanoma (n = 18, 16%). They were mainly treated with an anti-PD-(L)1 alone (n = 110, 96%). Main ICU admission reasons were acute respiratory failure (n = 66, 57%), colitis (n = 14, 13%), and cardiovascular disease (n = 13, 11%). ICU admission was considered "likely" associated with irAE for 48% (n = 55) of patients. Factors independently associated with irAE were a good ECOG performance status (PS) (ECOG-PS of 0 or 1 vs. ECOG-PS of 2-3, odds ratio [OR] = 6.34, 95% confidence interval [95% CI] 2.13-18.90, and OR = 3.66, 95% CI 1.33-10.03, respectively), and a history of irAE (OR = 3.28, 95% CI 1.19-9.01). Steroids were prescribed for 41/55 (75%) patients with ICU admission "likely" related to irAE. Three patients were subsequently treated with immunosuppressants. CONCLUSION IrAEs accounted for half of ICU admissions in cancer patients receiving ICIs. They could be treated with steroids. Identifying the imputability of irAEs in ICU admissions remains a challenge.
Collapse
Affiliation(s)
- Anne-Claire Toffart
- Department of Pneumology and Physiology, CHU Grenoble Alpes, Grenoble, France.
| | - Anne-Pascale Meert
- Department of Internal Medicine, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Florent Wallet
- Department of Resuscitation, Hospices Civils de Lyon, Lyon, France
| | - Aude Gibelin
- Department of Resuscitation, Hôpital Tenon, AP-HP, Paris, France
| | - Olivier Guisset
- Department of Intensive Care and Resuscitation, Hôpital Saint André, CHU Bordeaux, Bordeaux, France
| | | | - Amélie Seguin
- Department of Resuscitation, CHU de Nantes, Nantes, France
| | | | | | | | - Boris Duchemann
- Department of Thoracic Oncology, Hôpital Avicenne, Bobigny, France
| | | | - Martine Nyunga
- Department of Resuscitation, CH de Roubaix, Roubaix, France
| | - David Grimaldi
- Department of Resuscitation, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Albrice Levrat
- Department of Resuscitation, CH Annecy Genevois, Annecy, France
| | - Elie Azoulay
- Department of Resuscitation, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Virginie Lemiale
- Department of Resuscitation, Hôpital Saint-Louis, AP-HP, Paris, France
| |
Collapse
|
68
|
Hu Y, Liu C, Jin S, Yi Z, Wang C, Pan X, Huang H. A case of subclinical immune checkpoint inhibitor-associated myocarditis in non-small cell lung cancer. BMC Pulm Med 2023; 23:119. [PMID: 37060029 PMCID: PMC10103507 DOI: 10.1186/s12890-023-02417-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/04/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have been widely used in the treatment of cancer. Moreover, immune-related adverse events (irAEs) have become a new clinical challenge. ICI-associated myocarditis is a rare but fatal condition among diverse organ injuries, and early recognition and effective interventions are critical for patients. CASE PRESENTATION In this report, we present the case of a healthy 60-year-old male who was diagnosed with lung squamous cell carcinomas following chemotherapy and received ICIs. The patient presented with asymptomatic cardiac biomarker elevation followed by immune-related myocarditis. Fortunately, the patient achieved a good clinical result after receiving high-dose steroids. The treatment with ICIs was discontinued because of recurrent increases in troponin T. CONCLUSION ICI-mediated associated myocarditis is an uncommon but potentially life-threatening adverse event. The current data suggest that clinicians need to be cautious about reinitiation in low-grade patients; however, further study of the diagnosis and treatment is necessary.
Collapse
Affiliation(s)
- Yue Hu
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China.
- Cancer Center, Zhejiang University, Hangzhou, 310058, Zhejiang, China.
| | - Cuixia Liu
- Department of Respiratory and Critical Care Medicine, Songyang people's Hospital of Zhejiang, Lishui, 323499, Zhejiang, China
| | - Shaojun Jin
- Department of emergency, Zhuji people's Hospital of Zhejiang, Zhuji, 311800, Zhejiang, China
| | - Zihan Yi
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China
- Cancer Center, Zhejiang University, Hangzhou, 310058, Zhejiang, China
| | - Chao Wang
- Department of Radiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China
| | - Xiaohong Pan
- Department of Cardiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China
| | - Huaqiong Huang
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China.
- Cancer Center, Zhejiang University, Hangzhou, 310058, Zhejiang, China.
| |
Collapse
|
69
|
Xiao J, Li X, Wang X, Guan Y, Liu H, Liang J, Li Y, Wang B, Wang J. Clinical characteristics and management of immune checkpoint inhibitor-related cardiotoxicity: A single-center experience. Front Cardiovasc Med 2023; 10:1093383. [PMID: 37089888 PMCID: PMC10115988 DOI: 10.3389/fcvm.2023.1093383] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/06/2023] [Indexed: 04/08/2023] Open
Abstract
BackgroundImmune checkpoint inhibitors (ICIs) have revolutionized cancer therapy in the past decade and amplify T-cell-mediated immune responses by disrupting immunoinhibitory signals. The augmented T-cell immune response has led to a range of immune-related adverse effects (irAEs). Immune-related cardiotoxicity has been reported in case series but has been underappreciated due to difficulties in diagnosis. This article describes epidemiological, clinical presentation, subtype, and treatment data and a new systematic framework for the clinical management of cardiotoxicity.MethodsData were extracted for cancer patients who received ICIs in a single center between January 1, 2020, and February 28, 2022. ICI-associated cardiotoxicity was clinically diagnosed based on clinical presentations, biochemical biomarkers, and imaging features.ResultsWe identified a total of 12 (2.46%) cases of ICI-related cardiotoxicity from 487 patients who received PD-1 or PD-L1 inhibitors. All patients were diagnosed with advanced or metastatic solid tumors. The severity of ICI-related cardiotoxicity ranged from subclinical cardiac abnormalities (subclinical type) with only asymptomatic troponin-I (TnI) elevations (25.0%) to symptomatic cardiac abnormalities (clinical type) (75.0%). Patients with symptomatic cardiac abnormalities had several manifestations, including tachyarrhythmia (16.7%), bradyarrhythmia (41.7%), or cardiac failure (8.3%). The median immunotherapy exposure time was 1.5 doses (range: 1 to 5), and the median time from the initial immunotherapy to the onset of ICI-related cardiotoxicity was 33.5 days (IQR: 20.3 to 46.8). Most patients, including those with subclinical cardiac abnormalities, were administered systemic corticosteroids (58.3%). One (8.3%) patient was put on mechanical ventilation, one (8.3%) received plasma exchange therapy, one (8.3%) was implanted with a pacemaker, and one (8.3%) was admitted to the ICU. Three patients with symptomatic cardiac abnormalities (25.0%) died, and other patients presented with significant clinical improvement with good outcomes.ConclusionICI-related cardiotoxicity is uncommon but critical with a high mortality rate and poor prognosis, especially for a small group of patients with symptomatic cardiac abnormalities. More attention should be given to cardiotoxicity associated with ICIs, and these patients should be given baseline examinations and biochemical analyses before and after the initiation of immunotherapy, intensive cardiac assessments, an accurate and rapid diagnosis, and timely multidisciplinary management with immunosuppressive agents and other necessary clinical interventions.
Collapse
|
70
|
Myocarditis associated with immune-checkpoint inhibitors diagnosed by cardiac magnetic resonance imaging. Int Cancer Conf J 2023; 12:109-114. [PMID: 36896200 PMCID: PMC9989058 DOI: 10.1007/s13691-022-00588-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
Myocarditis associated with immune-checkpoint inhibitors (ICIs) is a rare, but critical adverse event. Although endomyocardial biopsy (EMB) is the standard for diagnosis of myocarditis, there is a possibility of false negatives due to sampling errors and local nonavailability of EMB, which may hamper the appropriate diagnosis of myocarditis. Therefore, an alternative criterion based on cardiac magnetic resonance imaging (CMRI) combined with clinical presentation has been proposed, but not emphasized sufficiently. We report a case of myocarditis after ICIs administration, which was diagnosed using CMRI in a 48-year-old male with lung adenocarcinoma. CMRI provides an opportunity to diagnose myocarditis during cancer treatment.
Collapse
|
71
|
Zhang Z, Zhu D, Shi P, Wu J, Li F, Chen Y. LncRNA XIST knockdown reduces myocardial damage in myocarditis by targeting the miR-140-3p/RIPK1 axis. Biotechnol Genet Eng Rev 2023:1-13. [DOI: 10.1080/02648725.2023.2194074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
|
72
|
Wang D, Bauersachs J, Berliner D. Immune Checkpoint Inhibitor Associated Myocarditis and Cardiomyopathy: A Translational Review. BIOLOGY 2023; 12:biology12030472. [PMID: 36979163 PMCID: PMC10045178 DOI: 10.3390/biology12030472] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized oncology and transformed the treatment of various malignancies. By unleashing the natural immunological brake of the immune system, ICIs were initially considered an effective, gentle therapy with few side effects. However, accumulated clinical knowledge reveals that ICIs are associated with inflammation and tissue damage in multiple organs, leading to immune-related adverse effects (irAEs). Most irAEs involve the skin and gastrointestinal tract; however, cardiovascular involvement is associated with very high mortality rates, and its underlying pathomechanisms are poorly understood. Ranging from acute myocarditis to chronic cardiomyopathies, ICI-induced cardiotoxicity can present in various forms and entities. Revealing the inciting factors, understanding the pathogenesis, and identifying effective treatment strategies are needed to improve the care of tumor patients and our understanding of the immune and cardiovascular systems.
Collapse
Affiliation(s)
- Dong Wang
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| |
Collapse
|
73
|
Jimenez J, Kostelecky N, Mitchell JD, Zhang KW, Lin CY, Lenihan DJ, Lavine KJ. Clinicopathological classification of immune checkpoint inhibitor-associated myocarditis: possible refinement by measuring macrophage abundance. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:14. [PMID: 36915213 PMCID: PMC10009938 DOI: 10.1186/s40959-023-00166-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/10/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI) myocarditis is associated with high morbidity and mortality. While endomyocardial biopsy (EMB) is considered a gold standard for diagnosis, the sensitivity of EMB is not well defined. Additionally, the pathological features that correlate with the clinical diagnosis of ICI-associated myocarditis remain incompletely understood. METHODS We retrospectively identified and reviewed the clinicopathological features of 26 patients with suspected ICI-associated myocarditis based on institutional major and minor criteria. Seventeen of these patients underwent EMB, and the histopathological features were assessed by routine hematoxylin and eosin (H&E) staining and immunohistochemical (IHC) staining for CD68, a macrophage marker. RESULTS Only 2/17 EMBs obtained from patients with suspected ICI myocarditis satisfied the Dallas criteria. Supplemental IHC staining and quantification of CD68+ macrophages identified an additional 7 patients with pathological features of myocardial inflammation (> 50 CD68+ cells/HPF). Macrophage abundance positively correlated with serum Troponin I (P = 0.010) and NT-proBNP (N-terminal pro-brain natriuretic peptide, P = 0.047) concentration. Inclusion of CD68 IHC could have potentially changed the certainty of the diagnosis of ICI-associated myocarditis to definite in 6/17 cases. CONCLUSIONS While the Dallas criteria can identify a subset of ICI-associated myocarditis patients, quantification of macrophage abundance may expand the diagnostic role of EMB. Failure to meet the traditional Dallas Criteria should not exclude the diagnosis of myocarditis.
Collapse
Affiliation(s)
- Jesus Jimenez
- Center for Cardiovascular Research, Department of Medicine, Cardiovascular Division, Washington University School of Medicine, 660 South Euclid Campus, Box 8086, St. Louis, MO, 63110, USA. .,Cardio-Oncology Center of Excellence, Department of Medicine, Cardiovascular Division, Washington University School of Medicine, 660 South Euclid Campus, Box 8086, St. Louis, MO, 63110, USA.
| | - Nicolas Kostelecky
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Joshua D Mitchell
- Cardio-Oncology Center of Excellence, Department of Medicine, Cardiovascular Division, Washington University School of Medicine, 660 South Euclid Campus, Box 8086, St. Louis, MO, 63110, USA
| | - Kathleen W Zhang
- Cardio-Oncology Center of Excellence, Department of Medicine, Cardiovascular Division, Washington University School of Medicine, 660 South Euclid Campus, Box 8086, St. Louis, MO, 63110, USA
| | - Chieh-Yu Lin
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel J Lenihan
- Cardio-Oncology Center of Excellence, Department of Medicine, Cardiovascular Division, Washington University School of Medicine, 660 South Euclid Campus, Box 8086, St. Louis, MO, 63110, USA
| | - Kory J Lavine
- Center for Cardiovascular Research, Department of Medicine, Cardiovascular Division, Washington University School of Medicine, 660 South Euclid Campus, Box 8086, St. Louis, MO, 63110, USA.,Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
74
|
Joolharzadeh P, Rodriguez M, Zaghlol R, Pedersen LN, Jimenez J, Bergom C, Mitchell JD. Recent Advances in Serum Biomarkers for Risk Stratification and Patient Management in Cardio-Oncology. Curr Cardiol Rep 2023; 25:133-146. [PMID: 36790618 PMCID: PMC9930715 DOI: 10.1007/s11886-022-01834-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 02/16/2023]
Abstract
PURPOSE OF REVIEW Following significant advancements in cancer therapeutics and survival, the risk of cancer therapy-related cardiotoxicity (CTRC) is increasingly recognized. With ongoing efforts to reduce cardiovascular morbidity and mortality in cancer patients and survivors, cardiac biomarkers have been studied for both risk stratification and monitoring during and after therapy to detect subclinical disease. This article will review the utility for biomarker use throughout the cancer care continuum. RECENT FINDINGS A recent meta-analysis shows utility for troponin in monitoring patients at risk for CTRC during cancer therapy. The role for natriuretic peptides is less clear but may be useful in patients receiving proteasome inhibitors. Early studies explore use of myeloperoxidase, growth differentiation factor 15, galectin 3, micro-RNA, and others as novel biomarkers in CTRC. Biomarkers have potential to identify subclinical CTRC and may reveal opportunities for early intervention. Further research is needed to elucidate optimal biomarkers and surveillance strategies.
Collapse
Affiliation(s)
- Pouya Joolharzadeh
- General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Mario Rodriguez
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Raja Zaghlol
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Lauren N Pedersen
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jesus Jimenez
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Carmen Bergom
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Joshua D Mitchell
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA.
- Alvin J. Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA.
| |
Collapse
|
75
|
Exploring the Cardiotoxicity Spectrum of Anti-Cancer Treatments: Definition, Classification, and Diagnostic Pathways. J Clin Med 2023; 12:jcm12041612. [PMID: 36836147 PMCID: PMC9962102 DOI: 10.3390/jcm12041612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Early detection and treatment of cancer have led to a noticeable reduction in both mortality and morbidity. However, chemotherapy and radiotherapy could exert cardiovascular (CV) side effects, impacting survival and quality of life, independent of the oncologic prognosis. In this regard, a high clinical index of suspicion is required by the multidisciplinary care team in order to trigger specific laboratory tests (namely natriuretic peptides and high-sensitivity cardiac troponin) and appropriate imaging techniques (transthoracic echocardiography along with cardiac magnetic resonance, cardiac computed tomography, and nuclear testing (if clinically indicated)), leading to timely diagnosis. In the near future, we do expect a more tailored approach to patient care within the respective community along with the widespread implementation of digital health tools.
Collapse
|
76
|
Naqash AR, Johnson DB, Moslehi JJ, Sharon E. Reply to S. Rossi et al and P. Palassin et al. J Clin Oncol 2023; 41:1157-1158. [PMID: 36318738 PMCID: PMC9928682 DOI: 10.1200/jco.22.01928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/28/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Abdul Rafeh Naqash
- Abdul Rafeh Naqash, MD, Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK; Douglas B. Johnson, MD, Division of Medical Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN; Javid J. Moslehi, MD, Section of Cardio-Oncology & Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA; and Elad Sharon, MD, MPH, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Douglas B. Johnson
- Abdul Rafeh Naqash, MD, Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK; Douglas B. Johnson, MD, Division of Medical Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN; Javid J. Moslehi, MD, Section of Cardio-Oncology & Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA; and Elad Sharon, MD, MPH, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Javid J. Moslehi
- Abdul Rafeh Naqash, MD, Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK; Douglas B. Johnson, MD, Division of Medical Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN; Javid J. Moslehi, MD, Section of Cardio-Oncology & Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA; and Elad Sharon, MD, MPH, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Elad Sharon
- Abdul Rafeh Naqash, MD, Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK; Douglas B. Johnson, MD, Division of Medical Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN; Javid J. Moslehi, MD, Section of Cardio-Oncology & Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA; and Elad Sharon, MD, MPH, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| |
Collapse
|
77
|
Palassin P, Faillie JL, Coustal C, Quantin X, Topart D, Roubille F, Maria ATJ. Underreporting of Major Cardiac Adverse Events With Immune Checkpoint Inhibitors in Clinical Trials: Importance of Postmarketing Pharmacovigilance Surveys. J Clin Oncol 2023; 41:1154-1156. [PMID: 36318740 DOI: 10.1200/jco.22.01603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Pascale Palassin
- Pascale Palassin, PharmD, PhD, and Jean-Luc Faillie, MD, PhD, Regional Pharmacovigilance Centre, Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, Montpellier, France; Cyrille Coustal, MD, Department of Internal Medicine-Multi-Organic Diseases, Local Referral Center for Rare Auto-immune Diseases, Montpellier University Hospital, Montpellier, France; Xavier Quantin, MD, PhD, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France; Delphine Topart, MD, Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France; François Roubille, MD, PhD, Department of Cardiology, Montpellier University Hospital, Montpellier, France; and Alexandre T.J. Maria, MD, PhD, Internal Medicine & Immuno-Oncology (MedIO), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Jean-Luc Faillie
- Pascale Palassin, PharmD, PhD, and Jean-Luc Faillie, MD, PhD, Regional Pharmacovigilance Centre, Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, Montpellier, France; Cyrille Coustal, MD, Department of Internal Medicine-Multi-Organic Diseases, Local Referral Center for Rare Auto-immune Diseases, Montpellier University Hospital, Montpellier, France; Xavier Quantin, MD, PhD, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France; Delphine Topart, MD, Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France; François Roubille, MD, PhD, Department of Cardiology, Montpellier University Hospital, Montpellier, France; and Alexandre T.J. Maria, MD, PhD, Internal Medicine & Immuno-Oncology (MedIO), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Cyrille Coustal
- Pascale Palassin, PharmD, PhD, and Jean-Luc Faillie, MD, PhD, Regional Pharmacovigilance Centre, Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, Montpellier, France; Cyrille Coustal, MD, Department of Internal Medicine-Multi-Organic Diseases, Local Referral Center for Rare Auto-immune Diseases, Montpellier University Hospital, Montpellier, France; Xavier Quantin, MD, PhD, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France; Delphine Topart, MD, Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France; François Roubille, MD, PhD, Department of Cardiology, Montpellier University Hospital, Montpellier, France; and Alexandre T.J. Maria, MD, PhD, Internal Medicine & Immuno-Oncology (MedIO), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Xavier Quantin
- Pascale Palassin, PharmD, PhD, and Jean-Luc Faillie, MD, PhD, Regional Pharmacovigilance Centre, Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, Montpellier, France; Cyrille Coustal, MD, Department of Internal Medicine-Multi-Organic Diseases, Local Referral Center for Rare Auto-immune Diseases, Montpellier University Hospital, Montpellier, France; Xavier Quantin, MD, PhD, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France; Delphine Topart, MD, Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France; François Roubille, MD, PhD, Department of Cardiology, Montpellier University Hospital, Montpellier, France; and Alexandre T.J. Maria, MD, PhD, Internal Medicine & Immuno-Oncology (MedIO), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Delphine Topart
- Pascale Palassin, PharmD, PhD, and Jean-Luc Faillie, MD, PhD, Regional Pharmacovigilance Centre, Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, Montpellier, France; Cyrille Coustal, MD, Department of Internal Medicine-Multi-Organic Diseases, Local Referral Center for Rare Auto-immune Diseases, Montpellier University Hospital, Montpellier, France; Xavier Quantin, MD, PhD, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France; Delphine Topart, MD, Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France; François Roubille, MD, PhD, Department of Cardiology, Montpellier University Hospital, Montpellier, France; and Alexandre T.J. Maria, MD, PhD, Internal Medicine & Immuno-Oncology (MedIO), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - François Roubille
- Pascale Palassin, PharmD, PhD, and Jean-Luc Faillie, MD, PhD, Regional Pharmacovigilance Centre, Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, Montpellier, France; Cyrille Coustal, MD, Department of Internal Medicine-Multi-Organic Diseases, Local Referral Center for Rare Auto-immune Diseases, Montpellier University Hospital, Montpellier, France; Xavier Quantin, MD, PhD, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France; Delphine Topart, MD, Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France; François Roubille, MD, PhD, Department of Cardiology, Montpellier University Hospital, Montpellier, France; and Alexandre T.J. Maria, MD, PhD, Internal Medicine & Immuno-Oncology (MedIO), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Alexandre T J Maria
- Pascale Palassin, PharmD, PhD, and Jean-Luc Faillie, MD, PhD, Regional Pharmacovigilance Centre, Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, Montpellier, France; Cyrille Coustal, MD, Department of Internal Medicine-Multi-Organic Diseases, Local Referral Center for Rare Auto-immune Diseases, Montpellier University Hospital, Montpellier, France; Xavier Quantin, MD, PhD, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France; Delphine Topart, MD, Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France; François Roubille, MD, PhD, Department of Cardiology, Montpellier University Hospital, Montpellier, France; and Alexandre T.J. Maria, MD, PhD, Internal Medicine & Immuno-Oncology (MedIO), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| |
Collapse
|
78
|
Berberine Alleviates Doxorubicin-Induced Myocardial Injury and Fibrosis by Eliminating Oxidative Stress and Mitochondrial Damage via Promoting Nrf-2 Pathway Activation. Int J Mol Sci 2023; 24:ijms24043257. [PMID: 36834687 PMCID: PMC9966753 DOI: 10.3390/ijms24043257] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
Doxorubicin (DOX)-related cardiotoxicity has been recognized as a serious complication of cancer chemotherapy. Effective targeted strategies for myocardial protection in addition to DOX treatment are urgently needed. The purpose of this paper was to determine the therapeutic effect of berberine (Ber) on DOX-triggered cardiomyopathy and explore the underlying mechanism. Our data showed that Ber markedly prevented cardiac diastolic dysfunction and fibrosis, reduced cardiac malondialdehyde (MDA) level and increased antioxidant superoxide dismutase (SOD) activity in DOX-treated rats. Moreover, Ber effectively rescued the DOX-induced production of reactive oxygen species (ROS) and MDA, mitochondrial morphological damage and membrane potential loss in neonatal rat cardiac myocytes and fibroblasts. This effect was mediated by increases in the nuclear accumulation of nuclear erythroid factor 2-related factor 2 (Nrf2) and levels of heme oxygenase-1 (HO-1) and mitochondrial transcription factor A (TFAM). We also found that Ber suppressed the differentiation of cardiac fibroblasts (CFs) into myofibroblasts, as indicated by decreased expression of α-smooth muscle actin (α-SMA), collagen I and collagen III in DOX-treated CFs. Pretreatment with Ber inhibited ROS and MDA production and increased SOD activity and the mitochondrial membrane potential in DOX-challenged CFs. Further investigation indicated that the Nrf2 inhibitor trigonelline reversed the protective effect of Ber on both cardiomyocytes and CFs after DOX stimulation. Taken together, these findings demonstrated that Ber effectively alleviated DOX-induced oxidative stress and mitochondrial damage by activating the Nrf2-mediated pathway, thereby leading to the prevention of myocardial injury and fibrosis. The current study suggests that Ber is a potential therapeutic agent for DOX-induced cardiotoxicity that exerts its effects by activating Nrf2.
Collapse
|
79
|
Grümme L, Schulze-Koops H. [Rheumatological side effects of checkpoint inhibitors and their treatment]. Z Rheumatol 2023; 82:187-194. [PMID: 36607420 DOI: 10.1007/s00393-022-01311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/07/2023]
Abstract
The spectrum of tumors for which checkpoint inhibitor (CI) treatment is used is constantly expanding. The European Medicines Agency has currently approved nine CIs: one anti-cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) CI, one anti-lymphocyte activation gene 3 (LAG-3) CI, four anti-programmed cell death protein 1 (PD-1) CIs and three anti-programmed death ligand 1 (PD-L1) CIs. By blocking immune checkpoints the physiological downregulation of T cell activity against autologous tissue is prevented. This results in an immunologically unregulated activation of T cells directed against malignant cells. Healthy tissue also expresses antigens and thereby continuously activates autologous T cells. Thus, the blockade of immune checkpoints can lead to T cell activity against healthy tissue (immune-related adverse events, irAE). The irAEs can occur in any organ system and approximately 10% of all patients under CI treatment develop rheumatological irAEs, mostly arthralgia and myalgia. The classification criteria of rheumatological diseases do not need to be met to initiate treatment and the primary goal of treatment of irAEs is to enable continuation of CI treatment. Rheumatological irAEs should be recognized and treated quickly. In the treatment of musculoskeletal irAEs, three stages can be defined. In the first stage, nonsteroidal anti-inflammatory drugs or intra-articular as well as systemic glucocorticoids are used. In the second stage, conventional synthetic and in the third stage, biologic disease-modifying antirheumatic drugs are used. The most severe musculoskeletal irAE is myositis with cardiac and/or respiratory involvement and/or myasthenia gravis. In addition to high-dose glucocorticoids, intravenous immunoglobulins or plasma exchange are used in treatment.
Collapse
Affiliation(s)
- Lea Grümme
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| | - Hendrik Schulze-Koops
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| |
Collapse
|
80
|
Mescherina NS, Stepchenko MA, Leontieva TS, Khardikova EM, Mikhailenko TS. Approaches to early diagnosis and prevention of cardiovascular toxicity induced by targeted drugs and immune checkpoint inhibitors in oncohematology: a literature review. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2023. [DOI: 10.15829/1728-8800-2023-3337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
The development of targeted drugs and immune checkpoint inhibitors (ICIs), as well as their implementation into clinical practice has allowed increasing the overall and event-free survival of oncohematological patients. Currently, assessment of the efficacy of a therapeutic strategy in each specific case includes the evaluation of an acceptable tolerability profile. The subject of discussion includes cardiovascular complications induced by target drugs and ICIs. The review mainly presents the issues of cardiovascular toxicity (CVT) in certain groups of oncohematological patients (with chronic lymphocytic leukemia, chronic myeloid leukemia, multiple myeloma). The spectrum of cardiovascular adverse effects associated with targeted and ICI therapy in oncohematological practice is quite wide — coronary artery disease, peripheral arterial disease, myocarditis, heart failure, arrhythmias, hypertension. The high importance of the problem of using targeted and immunosuppressive therapy dictates the need to predict adverse effects. The diagnosis of heart failure (one of CVT manifestations) is based on determining the decreased left ventricular ejection fraction during echocardiography, less often — during cardiac magnetic resonance imaging; global longitudinal myocardial strain is a significant parameter of preclinical heart failure, which is determined using the speckle tracking technique. To determine vascular toxicity, a special attention is paid to the vascular wall structure and microcirculation parameters — capillary density at rest, percentage of capillary recovery and perfused capillaries, stiffness index for large blood vessels, reflection index for small arteries, laboratory markers of inflammation and endothelial dysfunction (C-reactive protein, fibrinogen, homocysteine, endothelin 1, vascular endothelial growth factor). CVT prevention presumes the determination of the risk group, correction of risk factors, and administration of protective therapy to very high and high-risk patients. One of the promising directions for preventing vascular toxicity is the use of sodium-glucose linked transporter-2 inhibitors.
Collapse
|
81
|
Hematologic and Oncologic Emergencies. Crit Care Nurs Q 2023; 46:100-113. [DOI: 10.1097/cnq.0000000000000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
82
|
Heo GS, Diekmann J, Thackeray JT, Liu Y. Nuclear Methods for Immune Cell Imaging: Bridging Molecular Imaging and Individualized Medicine. Circ Cardiovasc Imaging 2023; 16:e014067. [PMID: 36649445 PMCID: PMC9858352 DOI: 10.1161/circimaging.122.014067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Inflammation is a key mechanistic contributor to the progression of cardiovascular disease, from atherosclerosis through ischemic injury and overt heart failure. Recent evidence has identified specific roles of immune cell subpopulations in cardiac pathogenesis that diverges between individual patients. Nuclear imaging approaches facilitate noninvasive and serial quantification of inflammation severity, offering the opportunity to predict eventual outcome, stratify patient risk, and guide novel targeted molecular therapies against specific leukocyte subpopulations. Here, we will discuss the established and emerging nuclear imaging methods to label and track exogenous and endogenous immune cells, with a particular focus on clinical situations in which targeted molecular inflammation imaging would be advantageous. The expanding options for imaging inflammation provide the foundation to bridge between molecular imaging and individual therapy.
Collapse
Affiliation(s)
- Gyu Seong Heo
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO (G.S.H., Y. L.)
| | - Johanna Diekmann
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany (J.D., J.T.T.)
| | - James T Thackeray
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany (J.D., J.T.T.)
| | - Yongjian Liu
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO (G.S.H., Y. L.)
| |
Collapse
|
83
|
Moraes TAPD, Dias FCR, Sarmento-Filha MJ, Camara CDA, Silva TMS, Torres SM, Souza IA, Pereira MDF, Morais DB, Silva Junior VA. Role of synthetical amynoquinone ethyl 2-(1,4-dioxo-1,4-dihydronaphthalen-2-ylamino) acetate in inhibition of Ehrlich's tumor. Pathol Res Pract 2023; 241:154272. [PMID: 36525850 DOI: 10.1016/j.prp.2022.154272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
Quinones are naturally or synthetically occurring secondary metabolites that have various bio-dynamics, highlighting their antitumor potential. This has been explored through their selective cytotoxicity, and studies in medicinal chemistry about the relation between biological activity versus chemical structure may lead to the solution of the toxicity problems associated with quinones. In this context, the antitumor effect of a synthetic naphthoquinone, named Ethyl 2-(1,4-Dioxo-1,4-Dihydronaphthalen-2-Ylamino) Acetate, was tested using mice transplanted with Ehrlich ascitic tumor as an experimental model. The acute toxicity test was performed using 30 mice that received the aminoquinone at doses of 100, 200, 300, and 600 mg/kg. After evaluation of the clinical findings in the spontaneous activity tests, the LD50 calculation for the test substance showed low levels of toxicity at doses lower than 244.11 ± 23.29 mg/kg. Thus, three experimental groups were established, where animals transplanted with tumor cells received NaCl vehicle solution (control, n = 6), and the others were treated with 71.7 mg/kg of Methotrexate (n = 6) or 20 mg/kg of Aminoquinone (n = 6). All administrations were intraperitoneal, in a single dose. Three days after the implantation of the tumor cells the animals were weighed daily and evaluated for tumor biometry and development. The treatments occurred five days after the implantation of the tumor cells and were extended for 7 more days. At the end of the 12-day experimental period, all animals were euthanized for biochemical and histopathological analyses of the tumors and vital organs. The spontaneous activity test showed that the amount of responses associated with the nervous system tends to increase with the increase in dosage, highlighting the excitatory effect on the central nervous system in almost all dosages employed, followed by depressant activities on this system. There was a significant tumor reduction, both in animals treated with methotrexate (71.7 %) and in those treated with aminoquinone (91.6 %) in the control group. There was no significant difference in tumor volume between the animals treated with aminoquinone or methotrexate. The histopathological analysis revealed that in both treatments there were fewer mitoses in the tumor mass compared to the control group. However, there was apparent toxicity to the liver, heart, and left kidney in the treatment with methotrexate compared to aminoquinone. The significant capacity for tumor reduction presented by aminoquinone allows pointing it as a promising alternative for the development of a more efficient drug to control tumor development, being necessary for the development of new studies to deepen the knowledge about its mechanisms of action.
Collapse
Affiliation(s)
| | | | - Maria José Sarmento-Filha
- Programa de Pós-Graduação em Desenvolvimento e Inovação Tecnológica em Medicamentos, Universidade Federal do Rio Grande do Norte - UFRN, Natal, RN, Brazil
| | - Celso de Amorim Camara
- Departamento de Química, Universidade Federal Rural de Pernambuco - UFRPE, Recife, PE, Brazil
| | | | - Sandra Maria Torres
- Departamento de Medicina Veterinária, Universidade Federal Rural de Pernambuco - UFRPE, Recife, PE, Brazil
| | - Ivone Antônia Souza
- Departamento de Antibióticos, Universidade Federal de Pernambuco - UFPE, Recife, PE, Brazil
| | | | - Danielle Barbosa Morais
- Departamento de Morfologia, Universidade Federal do Rio Grande do Norte - UFRN, Natal, RN, Brazil
| | | |
Collapse
|
84
|
Lim J, Walter HAW, de Bruin-Bon RACM, Jarings MC, Planken RN, Kok WEM, Raaphorst J, Pinto YM, Amin AS, Boekholdt SM, van der Kooi AJ. Multimodality Screening For (Peri)Myocarditis In Newly Diagnosed Idiopathic Inflammatory Myopathies: A Cross-Sectional Study. J Neuromuscul Dis 2023; 10:185-197. [PMID: 36683515 PMCID: PMC10041435 DOI: 10.3233/jnd-221582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Cardiac involvement in idiopathic inflammatory myopathy (IIM or "myositis") is associated with an approximate 4% mortality, but standardised screening strategies are lacking. OBJECTIVE We explored a multimodality screening on potentially reversible cardiac involvement -i.e. active (peri)myocarditis -in newly diagnosed IIM. METHODS We included adult IIM patients from 2017 to 2020. At time of diagnosis, patients underwent cardiac evaluation including laboratory biomarkers, electrocardiography, echocardiography, and cardiac magnetic resonance imaging (CMR). Based on 2019 consensus criteria for myocarditis, an adjudication committee made diagnoses of definite, probable, possible or no (peri)myocarditis. We explored diagnostic values of sequentially added diagnostic modalities by Constructing Classification and Regression Tree (CART) analysis in patients with definite/probable versus no (peri)myocarditis. RESULTS We included 34 IIM patients, in whom diagnoses of definite (six, 18%), probable (two, 6%), possible (11, 32%), or no (peri)myocarditis (15, 44%) were adjudicated. CART-analysis showed high-sensitivity cardiac troponin T (cut-off value < 2.3 times the upper limit of normal (xULN)) ruled out (peri)myocarditis with a sensitivity of 88%, while high-sensitivity troponin I (cut-off value > 2.9 xULN for females and > 1.8 xULN for males) ruled in (peri)myocarditis with a specificity of 100%. Applying high-sensitivity cardiac troponins with these cut-off values in a diagnostic algorithm without and with a CMR to the total population of 34 patients demonstrated a diagnostic accuracy for a clear diagnosis of probable/definite or no (peri)myocarditis of 59% and 68%, respectively. CONCLUSIONS A diagnostic algorithm for detection of (peri)myocarditis in adult IIM may consist of sequential testing with high-sensitivity cardiac troponins and CMR.
Collapse
Affiliation(s)
- Johan Lim
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Hannah A W Walter
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | | | - Myrthe C Jarings
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Science - Atherosclerosis & Ischemic Syndromes, Amsterdam, The Netherlands
| | - Wouter E M Kok
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost Raaphorst
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Yigal M Pinto
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ahmad S Amin
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anneke J van der Kooi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| |
Collapse
|
85
|
Li X, Peng W, Wu J, Yeung SCJ, Yang R. Advances in immune checkpoint inhibitors induced-cardiotoxicity. Front Immunol 2023; 14:1130438. [PMID: 36911712 PMCID: PMC9995967 DOI: 10.3389/fimmu.2023.1130438] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are approved as the first-line drug for treating many cancers and has shown significant survival benefits; however, it also causes immune-related adverse events (irAEs) while activating the immune system, involving multiple organs. Among them, cardiovascular immune-related adverse events (CV-irAE) are rare, but common causes of death in ICIs treated cancer patients, which manifest as myocardial, pericardial, vascular and other cardiovascular toxicities. Therefore, it is important that irAEs, especially CV-irAE should be carefully recognized and monitored during the whole ICIs treatment because early detection and treatment of CV-irAE can significantly reduce the mortality of such patients. Consequently, it is urgent to fully understand the mechanism and management strategies of CV-irAE. The effects of ICIs are multifaceted and the exact mechanism of CV-irAE is still elusive. Generally, T cells identify tumor cell antigens as well as antigen in cardiomyocytes that are the same as or homologous to those on tumor cells, thus causing myocardial damage. In addition, ICIs promote formation of cardiac troponin I (cTnI) that induces cardiac dysfunction and myocardial dilatation; moreover, ICIs also increase the production of cytokines, which promote infiltration of inflammation-linked molecules into off-target tissues. Currently, the management and treatment of cardiovascular toxicity are largely dependent on glucocorticoids, more strategies for prevention and treatment of CV-irAE, such as predictive markers are being explored. This review discusses risk factors, potential pathophysiological mechanisms, clinical manifestations, and management and treatment of CV-irAE, guiding the development of more effective prevention, treatment and management strategies in the future.
Collapse
Affiliation(s)
- Xiang Li
- Department of the Second Medical Oncology, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Wenying Peng
- Department of the Second Medical Oncology, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Jiao Wu
- Department of the Second Medical Oncology, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, TX, United States
| | - Runxiang Yang
- Department of the Second Medical Oncology, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| |
Collapse
|
86
|
Lopez-Mattei J, Yang EH, Baldassarre LA, Agha A, Blankstein R, Choi AD, Chen MY, Meyersohn N, Daly R, Slim A, Rochitte C, Blaha M, Whelton S, Dzaye O, Dent S, Milgrom S, Ky B, Iliescu C, Mamas MA, Ferencik M. Cardiac computed tomographic imaging in cardio-oncology: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). Endorsed by the International Cardio-Oncology Society (ICOS). J Cardiovasc Comput Tomogr 2023; 17:66-83. [PMID: 36216699 DOI: 10.1016/j.jcct.2022.09.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/01/2022] [Accepted: 09/12/2022] [Indexed: 11/21/2022]
Abstract
Cardio-Oncology is a rapidly growing sub-specialty of medicine, however, there is very limited guidance on the use of cardiac CT (CCT) in the care of Cardio-Oncology patients. In order to fill in the existing gaps, this Expert Consensus statement comprised of a multidisciplinary collaboration of experts in Cardiology, Radiology, Cardiovascular Multimodality Imaging, Cardio-Oncology, Oncology and Radiation Oncology aims to summarize current evidence for CCT applications in Cardio-Oncology and provide practice recommendations for clinicians.
Collapse
Affiliation(s)
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Ali Agha
- Department of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Ron Blankstein
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew D Choi
- Division of Cardiology and Department of Radiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Marcus Y Chen
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nandini Meyersohn
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, USA
| | - Ryan Daly
- Franciscan Health Indianapolis, Indianapolis, IN, USA
| | | | - Carlos Rochitte
- InCor Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Michael Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Seamus Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, NC, USA
| | - Sarah Milgrom
- Department of Radiation Oncology, University of Colorado, Boulder, CO, USA
| | - Bonnie Ky
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Cezar Iliescu
- Heart and Vascular Institute, Lee Health, Fort Myers, FL, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
87
|
Park BC, Narayanan S, Gavraldis A, Ye F, Fan R, Sullivan RJ, Boland G, Reynolds KL, Balko JM, Carlino MS, Long GV, Zubiri L, Menzies AM, Johnson DB. Rare immune-related adverse events in patients with melanoma: incidence, spectrum, and clinical presentations. Oncoimmunology 2023; 12:2188719. [PMID: 36926262 PMCID: PMC10012911 DOI: 10.1080/2162402x.2023.2188719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2023] Open
Abstract
Immune-related adverse events (irAEs) are side effects of immune checkpoint inhibitor therapy (ICI). While common irAEs have been well characterized, there are more limited data on rare immune related adverse events (RirAEs) due to low incidence. Lack of characterization of these entities has led to difficulties in accurate diagnosis and management. Here, we conducted a multi-institution analysis of all patients with stage III/IV melanoma who developed RirAEs after being treated with ICIs (anti-PD-1/L1, anti-CTLA-4, and combination PD-1/CTLA-4 blockade) at three institutions (Vanderbilt University Medical Center, Massachusetts General Hospital, and Melanoma Institute of Australia). RirAEs were defined as those occurring in approximately <1% of patients treated with anti-PD-1 or <2% with combination. Of 2834 patients who received ICIs, 82 developed RirAEs and were more common with combination PD-1/CTLA-4 blockade (4.6%) vs. anti-PD-1/L1 agents (2.8%). Overall median time from ICI start to RirAE was 86 days (interquartile range 42-235 days) with significantly earlier onset in combination therapy (p < 0.001). The spectrum of RirAEs spanned across several organ systems. Most RirAEs were grade 2 (57 [41.3%]) and grade 3 (40 [29.0%]) with relatively few grade 4 (11 [8.0%]) or 5 (5 [3.6%]) events. Steroid re-escalation (21.4%) or additional immunosuppression (13.8%) were commonly required. RirAE recurrence occurred in 22.6% with ICI rechallenge; 37.1% had new irAEs with rechallenge. In conclusion, RirAEs associated with ICIs in melanoma patients occurred, in aggregate, in 2-5% of patients treated with anti-PD-1-based therapy. Steroid re-escalation and alternative immunosuppression use were frequently required but fatal irAEs were fairly uncommon.
Collapse
Affiliation(s)
- Benjamin C Park
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Sathya Narayanan
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - Alexander Gavraldis
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Run Fan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan J Sullivan
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Genevieve Boland
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Kerry L Reynolds
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Justin M Balko
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matteo S Carlino
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, NSW, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Leyre Zubiri
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
88
|
Vasbinder A, Chen Y, Procureur A, Gradone A, Azam TU, Perry D, Shadid H, Anderson E, Catalan T, Blakely P, Nelapudi N, Fardous M, Bretagne MC, Adie SK, Pogue KT, Leja M, Yentz S, Schneider B, Fecher LA, Lao CD, Salem JE, Hayek SS. Biomarker Trends, Incidence, and Outcomes of Immune Checkpoint Inhibitor-Induced Myocarditis. JACC CardioOncol 2022; 4:689-700. [PMID: 36636441 PMCID: PMC9830199 DOI: 10.1016/j.jaccao.2022.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 12/24/2022] Open
Abstract
Background Myocarditis is a dreaded and unpredictable complication of immune checkpoint inhibitors (ICI). We sought to determine whether routinely measured biomarkers could be helpful in monitoring for ICI myocarditis. Objectives The authors examined biomarker trends of patients on ICI and their association with the incidence of ICI myocarditis and outcomes. Methods We conducted an observational cohort study of adults who received at least one dose of ICI at Michigan Medicine between June 2014 and December 2021 and underwent systematic serial testing for aspartate aminotransferase (AST) and alanine aminotransferase (ALT), creatine phosphokinase (CPK), and lactate dehydrogenase during ICI therapy. Results Among 2,606 patients (mean age 64 ± 13 years; 60.7% men), 27 (1.0%) were diagnosed with ICI myocarditis. At diagnosis, patients with myocarditis had an elevated high-sensitivity troponin T (100%), ALT (88.9%), AST (85.2%), CPK (88.9%), and lactate dehydrogenase (92.6%). Findings were confirmed in an independent cohort of 30 patients with biopsy-confirmed ICI myocarditis. A total of 95% of patients with ICI myocarditis had elevations in at least 3 biomarkers compared with 5% of patients without myocarditis. Among the noncardiac biomarkers, only CPK was associated (per 100% increase) with the development of myocarditis (HR: 1.83; 95% CI: 1.59-2.10) and all-cause mortality (HR: 1.10; 95% CI: 1.01-1.20) in multivariable analysis. Elevations in CPK had a sensitivity of 99% and specificity of 23% for identifying myocarditis. Conclusions ICI myocarditis is associated with changes in AST, ALT, and CPK. An increase in noncardiac biomarkers during ICI treatment, notably CPK, should prompt further evaluation for ICI myocarditis.
Collapse
Affiliation(s)
- Alexi Vasbinder
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - YeeAnn Chen
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Adrien Procureur
- Department of Pharmacology and Clinical Investigation Centre, Pitié-Salpêtrière Hospital, Sorbonne Universite, Paris, France
| | - Allison Gradone
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tariq U. Azam
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Perry
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Husam Shadid
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth Anderson
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tonimarie Catalan
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Pennelope Blakely
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Namratha Nelapudi
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mohamad Fardous
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Marie C. Bretagne
- Department of Pharmacology and Clinical Investigation Centre, Pitié-Salpêtrière Hospital, Sorbonne Universite, Paris, France
| | - Sarah K. Adie
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Kristen T. Pogue
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Monika Leja
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Yentz
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Bryan Schneider
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Leslie A. Fecher
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher D. Lao
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Joe-Elie Salem
- Department of Pharmacology and Clinical Investigation Centre, Pitié-Salpêtrière Hospital, Sorbonne Universite, Paris, France
| | - Salim S. Hayek
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA,Address for correspondence: Dr Salim Hayek, Department of Medicine, Division of Cardiology, University of Michigan Frankel Cardiovascular Center, 1500 East Medical Center Drive, CVC #2709, Ann Arbor, Michigan 48109, USA. @salimhayek
| |
Collapse
|
89
|
Thuny F, Bonaca MP, Cautela J. What Is the Evidence of the Diagnostic Criteria and Screening of Immune Checkpoint Inhibitor-Induced Myocarditis? JACC CardioOncol 2022; 4:624-628. [PMID: 36636431 PMCID: PMC9830188 DOI: 10.1016/j.jaccao.2022.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 12/24/2022] Open
Abstract
Myocarditis is a rare, but serious, complication of immune checkpoint inhibitor therapy. The diagnosis of immune checkpoint inhibitor–induced myocarditis is sometimes challenging because of clinical, biological, and imaging features. Diagnostic criteria have been proposed to help clinicians, but have never been validated to date. Some guidelines now recommend early detection by repeated troponin and ECG testing, but its role has not yet been clearly demonstrated.
Collapse
Key Words
- 2018-LL, 2018-Lake Louise
- ACS, acute coronary syndrome
- CMR, cardiac magnetic resonance
- ECG, electrocardiogram
- EMB, endomyocardial biopsy
- IC-OS, International Cardio-Oncology Society
- ICI, immune checkpoint inhibitor
- ICI-M, immune checkpoint inhibitor–induced myocarditis
- LGE, late gadolinium enhancement
- MACE, major cardiovascular events
- cTn, cardiac troponin
- diagnosis
- immunotherapy
- irAE, immune-related adverse event
- myocarditis
- screening
Collapse
Affiliation(s)
- Franck Thuny
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Department of Cardiology, Assistance Publique–Hôpitaux de Marseille, North Hospital, Marseille, France,Center for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Marseille, France,French Working Group of Cardio-Oncology, France,Address for correspondence: Prof Franck Thuny, University Mediterranean Center of Cardio-Oncology, North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015 Marseille, France. @franckthuny@CautelaJennifer@MarcBonaca
| | - Marc P. Bonaca
- Colorado Prevention Centre, Clinical Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jennifer Cautela
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Department of Cardiology, Assistance Publique–Hôpitaux de Marseille, North Hospital, Marseille, France,Center for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Marseille, France,French Working Group of Cardio-Oncology, France
| |
Collapse
|
90
|
Kondapalli L, Hsia J, Miller R, Flaig TW, Bonaca MP. Burden of Cardiovascular Disease in Immune Checkpoint Inhibitor-Treated Patients: Reconciling Adjudicated and Coded Outcomes. JACC CardioOncol 2022; 4:649-656. [PMID: 36636437 PMCID: PMC9830208 DOI: 10.1016/j.jaccao.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/08/2022] [Accepted: 09/15/2022] [Indexed: 12/24/2022] Open
Abstract
Background There is growing recognition of the risk of cardiovascular (CV) events, particularly myocarditis, in the context of immune checkpoint inhibitor (ICI) therapy; however, true event rates in real-world populations and in the background of CV disease remain uncertain. Objectives The authors sought to determine CV event occurrence in ICI-treated patients and assess the accuracy of diagnosis by International Classification of Diseases (ICD) code compared with adjudication using established definitions and full-source documentation review. Methods Electronic medical record extraction identified potential CV events in ICI-treated patients in the University of Colorado Health system. Two cardiologists independently adjudicated events using standardized definitions. Agreement between ICD codes and adjudicated diagnoses was assessed using the kappa statistic. Results The cohort comprised 1,813 ICI-treated patients with a mean follow-up of 4.6 ± 3.4 years (3.2 ± 3.2 years pre-ICI and 1.4 ± 1.4 years post-ICI). Venous thromboembolic events (VTEs) were the most common event, occurring in 11.4% of patients pre-ICI and 11.3% post-ICI therapy. Post-ICI therapy, the crude rates of myocardial infarction (MI), heart failure, and stroke were 3.0%, 2.8%, and 1.6%, respectively. Six patients (0.3%) developed myocarditis post-ICI. Agreement between the ICD code and adjudication was greater for VTE (κ = 0.82; 95% CI: 0.79-0.85) and MI (κ = 0.74; 95% CI: 0.66-0.82) and worse for myocarditis (κ = 0.50; 95% CI: 0.20-0.80) and heart failure (κ = 0.47; 95% CI: 0.40-0.54). Conclusions ICD codes correlated well with adjudicated events for VTE and MI, but correlation was worse for heart failure and myocarditis. Adjudication with standardized definitions can enhance the understanding of the incidence of CV events related to ICI therapy.
Collapse
Affiliation(s)
- Lavanya Kondapalli
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA,Address for correspondence: Dr Lavanya Kondapalli, Division of Cardiology, University of Colorado School of Medicine, 12631 East 17th Avenue, Mail Stop B130, Aurora, Colorado 80045, USA. @CardioOncCO@cpcresearch
| | - Judith Hsia
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA,CPC Clinical Research, Aurora, Colorado, USA
| | - Ronni Miller
- UCHealth Anschutz Medical Campus, Aurora, Colorado, USA
| | - Thomas W. Flaig
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Marc P. Bonaca
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA,CPC Clinical Research, Aurora, Colorado, USA
| |
Collapse
|
91
|
Tan S, Day D, Nicholls SJ, Segelov E. Immune Checkpoint Inhibitor Therapy in Oncology: Current Uses and Future Directions: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:579-597. [PMID: 36636451 PMCID: PMC9830229 DOI: 10.1016/j.jaccao.2022.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/07/2022] [Indexed: 12/24/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a major class of immuno-oncology therapeutics that have significantly improved the prognosis of various cancers, both in (neo)adjuvant and metastatic settings. Unlike other conventional therapies, ICIs elicit antitumor effects by enhancing host immune systems to eliminate cancer cells. There are 3 approved ICI classes by the U.S. Food and Drug Administration: inhibitors targeting cytotoxic T lymphocyte associated antigen 4, programmed death 1/programmed death-ligand 1, and lymphocyte-activation gene 3, with many more in development. ICIs are commonly associated with distinct toxicities, known as immune-related adverse events, which can arise during treatment or less frequently be of late onset, usually relating to excessive activation of the immune system. Acute cardiovascular immune-related adverse events such as myocarditis are rare; however, data suggesting chronic cardiovascular sequelae are emerging. This review presents the current landscape of ICIs in oncology, with a focus on important aspects relevant to cardiology.
Collapse
Affiliation(s)
- Sean Tan
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia,Monash Heart, Monash Health, Clayton, Victoria, Australia,Address for correspondence: Dr Sean Tan, Victorian Heart Institute, Monash University, Wellington Road, Victoria 3800, Australia. @_SeanXTan
| | - Daphne Day
- School of Clinical Sciences, Monash Health, Monash University, Melbourne, Victoria, Australia,Department of Oncology, Monash Health, Clayton, Victoria, Australia
| | - Stephen J. Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia,Monash Heart, Monash Health, Clayton, Victoria, Australia
| | - Eva Segelov
- School of Clinical Sciences, Monash Health, Monash University, Melbourne, Victoria, Australia,Department of Oncology, Monash Health, Clayton, Victoria, Australia
| |
Collapse
|
92
|
Itzhaki Ben Zadok O, Shiyovich A, Hamdan A, Yeshurun M, Nardi Agmon I, Raanani P, Kornowski R, Shargian L. Anti-immunoglobulin-like transcript 3 induced acute myocarditis-A case report. Front Cardiovasc Med 2022; 9:1035569. [PMID: 36568550 PMCID: PMC9772458 DOI: 10.3389/fcvm.2022.1035569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/17/2022] [Indexed: 12/13/2022] Open
Abstract
To the best of our knowledge, this is the first published report of anti-immunoglobulin-like transcript 3 (ILT3)-induced myocarditis. A 48-year old female patient with refractory acute myeloid leukemia who was given a single dose of anti-ILT3 monotherapy presented with fever, hypotension, chest pain, and elevated cardiac biomarkers. Systolic bi-ventricular function was in normal limits. The patient was promptly treated with pulse dose steroids with a rapid hemodynamic and clinical improvement and declining levels of cardiac biomarkers. The diagnosis of acute myocarditis was confirmed using cardiac magnetic resonance imaging applying the revised Lake Lewis criteria. While larger-scale data are needed in order to assess the incidence, management and prognosis of anti-ILT-3 induced myocarditis, we believe a high level of suspicion for adverse non-target cardiac effects is required in patients receiving this novel class of drugs.
Collapse
Affiliation(s)
- Osnat Itzhaki Ben Zadok
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,*Correspondence: Osnat Itzhaki Ben Zadok
| | - Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ashraf Hamdan
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Yeshurun
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Inbar Nardi Agmon
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Shargian
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| |
Collapse
|
93
|
Chiang CH, Chiang CH, Ma KSK, Hsia YP, Lee YW, Wu HR, Chiang CH, Peng CY, Wei JCC, Shiah HS, Peng CM, Neilan TG. The incidence and risk of cardiovascular events associated with immune checkpoint inhibitors in Asian populations. Jpn J Clin Oncol 2022; 52:1389-1398. [PMID: 36208180 PMCID: PMC9721460 DOI: 10.1093/jjco/hyac150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/30/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Immune checkpoint inhibitors are associated with adverse cardiovascular events. However, there are no data characterizing cardiovascular events among Asians on immune checkpoint inhibitors. We aim to determine the incidence and risk of cardiac events associated with immune checkpoint inhibitors in an Asian population. METHODS We performed a retrospective, propensity score-matched cohort study at two tertiary referral centers in Taiwan. Immune checkpoint inhibitor users were matched with non-immune checkpoint inhibitor users based on predetermined clinical variables. The primary outcome was major adverse cardiovascular events, defined as a composite of myocardial infarction, ischemic stroke, acute peripheral occlusive disease, pulmonary embolism, deep venous thrombosis, heart failure, pericardial disease, myocarditis, cardiac arrhythmias and conduction block. RESULTS Between January 2010 and November 2021, 868 immune checkpoint inhibitor users were matched 1:1 with non-immune checkpoint inhibitor users. Among immune checkpoint inhibitor users, 67 (7.7%) patients developed major adverse cardiovascular events. During a median follow-up period of 188 days, the incidence rate of major adverse cardiovascular events for immune checkpoint inhibitor and non-immune checkpoint inhibitor users was 94.8 and 46.2 per 1000 patient-years, respectively, resulting in an incidence rate ratio of 2.1 [95% confidence interval: 1.5-2.9]. In multivariate Cox proportional hazard models, immune checkpoint inhibitor users had a 60% increased risk for major adverse cardiovascular events [hazard ratio, 1.6 (95% confidence interval: 1.1-2.3)]. Immune checkpoint inhibitors use was independently associated with increased risk of ischemic stroke [hazard ratio, 3.0 (95% confidence interval: 1.0-9.0)] and pulmonary embolism [hazard ratio, 5.5 (95% confidence interval: 1.4-21.3)]. In multivariate logistic regression analysis, age > 65, metastatic disease, hypertension and baseline platelet-to-lymphocyte ratio < 180 were risk factors for major adverse cardiovascular events. CONCLUSIONS Among Asians, immune checkpoint inhibitors were associated with an increased risk of major adverse cardiovascular events, particularly ischemic stroke and pulmonary embolism.
Collapse
Affiliation(s)
- Cho-Han Chiang
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, MA, USA
| | - Cho-Hung Chiang
- Department of General Division, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kevin Sheng-Kai Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Graduate Institute of Biomedical Electronics and Bioinformatics, College of Electrical Engineering and Computer Science, National Taiwan University, Taipei, Taiwan
| | - Yuan Ping Hsia
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Foundation, New Taipei City, Taiwan
| | - Yu-wen Lee
- Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Han-Ru Wu
- Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Cho-Hsien Chiang
- Department of Medical Education, Kuang Tien General Hospital, Taichung, Taiwan
- London School of Hygiene & Tropical Medicine, London, UK
| | - Chun-Yu Peng
- Department of Medicine, Danbury Hospital, Danbury, Connecticut, USA
- Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Her-Shyong Shiah
- Department of Hematology and Oncology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Ming Peng
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Foundation, New Taipei City, Taiwan
- Da Vinci Minimally Invasive Surgery Center, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
94
|
Pons-Riverola A, Ghosh AK. An Update on the Role of Cardiac Magnetic Resonance Imaging in Cancer Patients. Curr Cardiol Rep 2022; 24:2139-2147. [PMID: 36342641 DOI: 10.1007/s11886-022-01818-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE OF REVIEW Cardiac magnetic resonance imaging has a significant and expanding role to play in contemporary cardio-oncology. This review seeks to explore the current and future roles of this imaging modality in the cardio-oncology setting. RECENT FINDINGS Cardiac magnetic resonance imaging is required in diagnosing, monitoring and treating all types of cardiotoxicities (acute coronary syndromes, arrhythmias, myocarditis, pericardial disease, heart failure) and in all types of cancers (breast, gastrointestinal, renal, prostate, haematological etc.). Newer imaging sequences and techniques can help provide additional information and shorten imaging times. Cardiac magnetic resonance imaging is an integral part of the holistic management of cardio-oncology patients, with increasingly expanding applications in the area.
Collapse
Affiliation(s)
- Alexandra Pons-Riverola
- Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardio-Oncology Unit, Cardiology Department, Bellvitge University Hospital and Catalan Institute of Oncology (ICO), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Arjun K Ghosh
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew's Hospital, London, UK. .,Cardio-Oncology Service, Hatter Cardiovascular Institute, University College London, London, UK. .,William Harvey Research Institute, Queen Mary University of London, London, UK.
| |
Collapse
|
95
|
Maria ATJ, Delmas C, Coustal C, Palassin P, Roubille F. Immune checkpoint inhibitor-associated myocarditis and coronary artery disease: There may be more than meets the eye! Eur J Cancer 2022; 177:194-196. [PMID: 36809166 DOI: 10.1016/j.ejca.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/24/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Alexandre T J Maria
- Internal Medicine & Immuno-Oncology (MedI(2)O), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Clement Delmas
- Cardiology Department INI-CRT PhyMedExp INSERM CNRS CHU de Montpellier Université de Montpellier France, France
| | - Cyrille Coustal
- Department of Internal Medicine, Multi-Organic Diseases, Local Referral Center for Rare Auto-immune Diseases, Montpellier University Hospital, Montpellier, France
| | - Pascale Palassin
- Regional Pharmacovigilance Centre, Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, Montpellier, France
| | - François Roubille
- Cardiology Department INI-CRT PhyMedExp INSERM CNRS CHU de Montpellier Université de Montpellier France, France.
| |
Collapse
|
96
|
Andres MS, Ramalingam S, Rosen SD, Baksi J, Khattar R, Kirichenko Y, Young K, Yousaf N, Okines A, Huddart R, Harrington K, Furness AJS, Turajlic S, Pickering L, Popat S, Larkin J, Lyon AR. The spectrum of cardiovascular complications related to immune-checkpoint inhibitor treatment : Including myocarditis and the new entity of non inflammatory left ventricular dysfunction. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2022; 8:21. [PMID: 36424659 PMCID: PMC9685864 DOI: 10.1186/s40959-022-00147-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The full range of cardiovascular complications related to the use of Immune checkpoint inhibitors (ICI) is not fully understood. We aim to describe the spectrum of cardiovascular adverse events (cvAEs) by presenting our real-world experience of the diagnosis and management of these complications. METHODS Two thousand six hundred and forty-seven (2647) patients were started on ICI treatment between 2014 and 2020. Data from 110 patients referred to the cardio-oncology service with a suspected cvAE was collected prospectively and analysed. RESULTS Eighty-nine patients (3.4%) were confirmed to have cvAEs while on ICI therapy. Myocarditis was the most frequent event (33/89), followed by tachyarrhythmia (27/89), non-inflammatory left ventricular dysfunction (NILVD) (15/89) and pericarditis (7/89). Results from myocarditis and non-inflammatory left ventricular dysfunction cohorts were compared. Myocarditis and NILVD showed significant differences in respect toof troponin elevation, cardiac magnetic resonance abnormalities and ventricular function. Dual ICI therapy and other immune related adverse events were more frequently associated with myocarditis than NILVD. There was a significant difference in the median time from starting ICI treatment to presentation with myocarditis versus NILVD (12 vs 26 weeks p = 0.049). Through early recognition of myocarditis, prompt treatment with steroids and interruption of ICI, there were no cardiovascular in-hospital deaths. NILVD did not require steroid treatment and ICI could be restarted safely. CONCLUSIONS The full spectrum of cardiovascular complications in patients with immune checkpoint inhibitors is much broader than initially described. Myocarditis remains the most frequent cvAE related to ICI treatment. A novel type of myocardial injury was observed and defined as Atrial tachyarrhythmias and NILVD were also frequent in this cohort. NILVD has a This differs fromdifferent presentation from ICI-related myocarditis, mainly usually presenting afterby the lack of inflammatory features on CMR and biomarkers and a later presentation in time.
Collapse
Affiliation(s)
- Maria Sol Andres
- Cardio-Oncology Service, Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP, London, UK.
| | - Sivatharshini Ramalingam
- Cardio-Oncology Service, Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP, London, UK
| | - Stuart D Rosen
- Cardio-Oncology Service, Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John Baksi
- Cardio-Oncology Service, Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP, London, UK
| | - Rajdeep Khattar
- Cardio-Oncology Service, Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP, London, UK
| | - Yulia Kirichenko
- Cardio-Oncology Service, Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP, London, UK
- Department of Hospital Therapy N°1, Sechenov University, Moscow, Russia
| | - Kate Young
- Royal Marsden Hospital Foundation Trust, London, UK
| | - Nadia Yousaf
- Royal Marsden Hospital Foundation Trust, London, UK
| | | | | | | | | | | | | | - Sanjay Popat
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Marsden Hospital Foundation Trust, London, UK
| | - James Larkin
- Royal Marsden Hospital Foundation Trust, London, UK
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
97
|
Nishikawa T, Inoue T, Otsuka T, Kuno I, Kukita Y, Nakamura H, Ikeda Y, Yasui T, Shioyama W, Oka T, Honma K, Hatakeyama K, Miyata H, Isei T, Ishihara R, Kumagai T, Nishimura K, Fujita M. Prevalence and characteristics of immune checkpoint inhibitor-related myocardial damage: A prospective observational study. PLoS One 2022; 17:e0275865. [PMCID: PMC9665386 DOI: 10.1371/journal.pone.0275865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022] Open
Abstract
An increasing number of patients with cancer are being treated with immune checkpoint inhibitors. Consequently, the incidence of immune checkpoint inhibitor-related myocarditis has been increasing. Nonetheless, the diagnostic criteria for the immune checkpoint inhibitor-related myocarditis have not been sufficiently established. Therefore, the real-world incidence or prevalence of immune checkpoint inhibitor-related myocardial damage remains unknown. This was a single-center cohort study that included 100 patients admitted for immune checkpoint inhibitor therapy for any type of cancer. The patients underwent monthly measurement of cardiac troponin I and N-terminal pro-brain natriuretic peptide levels with electrocardiography. Additionally, echocardiography was performed every 3 months. Our protocol was continued until 6 months after the initiation of immune checkpoint inhibitors. We defined immune checkpoint inhibitor-related myocardial damage as an increase in cardiac troponin I levels by >0.026 ng/mL and/or a decrease in the left ventricular ejection fraction by >10% to <53% on echocardiography. The mean patient age was 64 years; 71% were men. The most commonly used immune checkpoint inhibitor was nivolumab (47%), followed by pembrolizumab (29%). Overall, 5% of patients received combination therapy. Among 100 patients, 10 (10%) were diagnosed with immune checkpoint inhibitor-related myocardial damage. Among them, five patients underwent endomyocardial biopsy. Of these patients, four were histopathologically observed to have lymphocyte infiltration in their myocardium. In conclusion, serial cardiac troponin I measurement during immune checkpoint inhibitor treatment could help detect early-phase myocardial damage. The prevalence of myocardial damage was much higher than previously expected.
Collapse
Affiliation(s)
- Tatsuya Nishikawa
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
- * E-mail: (TN); (MF)
| | - Takako Inoue
- Department of Thoracic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Tomoyuki Otsuka
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ikumi Kuno
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoji Kukita
- Laboratory of Genomic Pathology, Osaka International Cancer Institute, Osaka, Japan
| | - Harumi Nakamura
- Laboratory of Genomic Pathology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshihiko Ikeda
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Taku Yasui
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Wataru Shioyama
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Toru Oka
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Keiichirou Honma
- Department of Pathology, Osaka International Cancer Institute, Osaka, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Miyata
- Department of Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Taiki Isei
- Department of Dermatological Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Toru Kumagai
- Department of Thoracic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuo Nishimura
- Department of Urology, Osaka International Cancer Institute, Osaka, Japan
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
- * E-mail: (TN); (MF)
| |
Collapse
|
98
|
Rivera JA, Aragon D, Gomez J, Arredondo H, Thomas PM, Dominici P, Akala OO, Menowsky M. Acute Hypersensitivity Reaction After Casirivimab/Imdevimab Infusion in a COVID-19-Positive Young Male: Myopericarditis or Kounis Syndrome? Cureus 2022; 14:e31125. [DOI: 10.7759/cureus.31125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2022] [Indexed: 11/06/2022] Open
|
99
|
Chen R, Zhou M, Zhu F. Immune Checkpoint Inhibitors Related to Cardiotoxicity. J Cardiovasc Dev Dis 2022; 9:jcdd9110378. [PMID: 36354777 PMCID: PMC9697232 DOI: 10.3390/jcdd9110378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have now emerged as a mainstay of treatment for various cancers. Along with development of ICIs, immune-related adverse effects (irAEs) have aroused wide attention. The cardiac irAE, one of the rare but potentially fatal effects, have been reported recently. However, the clinical comprehension of cardiac irAEs remains limited and guidelines are inadequate for cardio-oncologists to tackle the problem. In this review, we have summarized current classifications of, manifestations of, potential mechanisms of, and treatment for ICI-related myocardial injury in order to provide some clues for the understanding of cardiac irAEs in clinical work.
Collapse
Affiliation(s)
- Ru Chen
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Clinic Center of Human Gene Research, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Min Zhou
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Key Laboratory of Respiratory Diseases, National Ministry of Health of the People’s Republic of China and National Clinical Research Center for Respiratory Disease, Wuhan 430022, China
- Correspondence: (M.Z.); (F.Z.)
| | - Feng Zhu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Clinic Center of Human Gene Research, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Correspondence: (M.Z.); (F.Z.)
| |
Collapse
|
100
|
Zhang Y, Sun C, Li Y, Qin J, Amancherla K, Jing Y, Hu Q, Liang K, Zhang Z, Ye Y, Huang LA, Nguyen TK, Egranov SD, Zhao Z, Wu A, Xi Y, Yao J, Hung MC, Calin GA, Cheng J, Lim B, Lehmann LH, Salem JE, Johnson DB, Curran MA, Yu D, Han L, Darabi R, Yang L, Moslehi JJ, Lin C. Hormonal therapies up-regulate MANF and overcome female susceptibility to immune checkpoint inhibitor myocarditis. Sci Transl Med 2022; 14:eabo1981. [PMID: 36322628 PMCID: PMC9809130 DOI: 10.1126/scitranslmed.abo1981] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have been increasingly used in combination for cancer treatment but are associated with myocarditis. Here, we report that tumor-bearing mice exhibited response to treatment with combinatorial anti-programmed cell death 1 and anti-cytotoxic T lymphocyte antigen-4 antibodies but also presented with cardiovascular toxicities observed clinically with ICI therapy, including myocarditis and arrhythmia. Female mice were preferentially affected with myocarditis compared to male mice, consistent with a previously described genetic model of ICI myocarditis and emerging clinical data. Mechanistically, myocardial tissue from ICI-treated mice, the genetic mouse model, and human heart tissue from affected patients with ICI myocarditis all exhibited down-regulation of MANF (mesencephalic astrocyte-derived neurotrophic factor) and HSPA5 (heat shock 70-kDa protein 5) in the heart; this down-regulation was particularly notable in female mice. ICI myocarditis was amplified by heart-specific genetic deletion of mouse Manf and was attenuated by administration of recombinant MANF protein, suggesting a causal role. Ironically, both MANF and HSPA5 were transcriptionally induced by liganded estrogen receptor β and inhibited by androgen receptor. However, ICI treatment reduced serum estradiol concentration to a greater extent in female compared to male mice. Treatment with an estrogen receptor β-specific agonist and androgen depletion therapy attenuated ICI-associated cardiac effects. Together, our data suggest that ICI treatment inhibits estradiol-dependent expression of MANF/HSPA5 in the heart, curtailing the cardiomyocyte response to immune injury. This endocrine-cardiac-immune pathway offers new insights into the mechanisms of sex differences in cardiac disease and may offer treatment strategies for ICI myocarditis.
Collapse
Affiliation(s)
- Yaohua Zhang
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, 10069, China.,Corresponding author. (Y.Z.); (L.Y.); (J.J.M.); and (C.L.)
| | - Chengcao Sun
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Yajuan Li
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Current address: Incyte Corporation, Wilmington, DE 19803, USA
| | - Juan Qin
- Section of Cardio-Oncology & Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Kaushik Amancherla
- Department of Medicine, Vanderbilt University of Medical Center, Nashville, TN 37232
| | - Ying Jing
- Department of Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030, USA
| | - Qingsong Hu
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Current address: The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, P.R. China
| | - Ke Liang
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Zhao Zhang
- Department of Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030, USA
| | - Youqiong Ye
- Department of Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030, USA
| | - Lisa A. Huang
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Tina K. Nguyen
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Sergey D. Egranov
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Zilong Zhao
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Andrew Wu
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Yutao Xi
- Texas Heart Institute, St. Luke’s Hospital, Houston, TX 77030, USA
| | - Jun Yao
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Mien-Chie Hung
- Graduate Institute of Biomedical Sciences, Research Center for Cancer Biology, and Center for Molecular Medicine, China Medical University, Taichung 404, Taiwan.,Department of Biotechnology, Asia University, Taichung 413, Taiwan
| | - George A. Calin
- Department of Experimental Therapeutics, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Center for RNA Interference and Non-Coding RNAs, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Jie Cheng
- Texas Heart Institute, St. Luke’s Hospital, Houston, TX 77030, USA
| | - Bora Lim
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lorenz H. Lehmann
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany; Cardio-Oncology Unit, Heidelberg University Hospital, Heidelberg, Germany; German Cardiovascular Research Center (DZHK), partner site Heidelberg/Mannheim, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Joe-Elie Salem
- Deprtment of Pharmacology, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, INSERM, CIC-1901, UNICO-GRECO Cardiooncology Program, Paris, France
| | - Douglas B. Johnson
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Michael A. Curran
- Department of Immunology and Scientific Director of the Oncology Research for Biologics and Immunotherapy Translation (ORBIT), The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Dihua Yu
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,The Graduate School of Biomedical Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Leng Han
- Center for Epigenetics and Disease Prevention, Institute of Biosciences and Technology, Texas A&M University, Houston, TX, 77030, USA
| | - Radbod Darabi
- Center for Stem Cell and Regenerative Medicine (CSCRM), The Brown Foundation Institute of Molecular Medicine for the Prevention of Human Diseases (IMM), The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Liuqing Yang
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Center for RNA Interference and Non-Coding RNAs, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,The Graduate School of Biomedical Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Corresponding author. (Y.Z.); (L.Y.); (J.J.M.); and (C.L.)
| | - Javid J. Moslehi
- Section of Cardio-Oncology & Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, 94143, USA,Corresponding author. (Y.Z.); (L.Y.); (J.J.M.); and (C.L.)
| | - Chunru Lin
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,The Graduate School of Biomedical Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Corresponding author. (Y.Z.); (L.Y.); (J.J.M.); and (C.L.)
| |
Collapse
|