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Sawicki KT, Sala V, Prever L, Hirsch E, Ardehali H, Ghigo A. Preventing and Treating Anthracycline Cardiotoxicity: New Insights. Annu Rev Pharmacol Toxicol 2021; 61:309-332. [PMID: 33022184 DOI: 10.1146/annurev-pharmtox-030620-104842] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Anthracyclines are the cornerstone of many chemotherapy regimens for a variety of cancers. Unfortunately, their use is limited by a cumulative dose-dependent cardiotoxicity. Despite more than five decades of research, the biological mechanisms underlying anthracycline cardiotoxicity are not completely understood. In this review, we discuss the incidence, risk factors, types, and pathophysiology of anthracycline cardiotoxicity, as well as methods to prevent and treat this condition. We also summarize and discuss advances made in the last decade in the comprehension of the molecular mechanisms underlying the pathology.
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Affiliation(s)
- Konrad Teodor Sawicki
- Division of Cardiology, Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA;
| | - Valentina Sala
- Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy;
| | - Lorenzo Prever
- Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy;
| | - Emilio Hirsch
- Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy;
| | - Hossein Ardehali
- Division of Cardiology, Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA;
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy;
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52
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Cardiac complications associated with hematopoietic stem-cell transplantation. Bone Marrow Transplant 2021; 56:2637-2643. [PMID: 34381168 DOI: 10.1038/s41409-021-01427-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 12/11/2022]
Abstract
Advances in chemotherapy and supportive therapy have resulted in improved clinical outcomes in patients with hematological malignancies undergoing hematopoietic stem-cell transplantation (HSCT). However, the association between HSCT and early- and late-onset cardiotoxicity remains controversial as these cardiac complications, including acute heart failure and arrhythmia, such as atrial fibrillation, can occasionally be lethal. Although the overall pathophysiology has not been elucidated, initial/salvage chemotherapy before HSCT, such as anthracycline-combined regimens, conditioning regimens, thoracic radiotherapy, and pre-existing personal risk factors, could be associated with an increased risk of cardiac events. Routine monitoring of cardiac function using global longitudinal strain or left ventricular ejection fraction in echocardiogram and serum biomarkers could be an option to detect early changes in cardiac status before irreversible cardiac complications develop. While beta-blockers and angiotensin-converting enzyme inhibitors are commonly used for cardioprotection, their clinical benefit has not been fully established in HSCT-associated cardiotoxicity. In the future, genetic analysis to reveal individual vulnerability to cardiotoxicity and prospective trials assessing the clinical benefit of early interventions, including novel agents such as angiotensin receptor-neprilysin inhibitor, are warranted. Collaboration between oncologists and cardiologists is crucial to establishing a strategy to prevent cardiac complications.
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Luongo C, Randazzo E, Iughetti L, DI Iorgi N, Loche S, Maghnie M, Valerio G, Delvecchio M. Cardiometabolic risk in childhood cancer survivors. Minerva Pediatr (Torino) 2021; 73:588-605. [PMID: 34309347 DOI: 10.23736/s2724-5276.21.06544-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Italian Cancer Registry Association has estimated that for the five-year period 2016-2020, in line with the previous five years, approximately 7,000 neoplasms have been diagnosed among children and 4,000 among adolescents. Leukemias, brain tumors and lymphomas together account for more than two-thirds of all pediatric cancers. Fortunately, the five-years survival rate has progressively improved reaching 80% thanks to the continuing improvement of therapeutic protocols but the vast majority of these cancer survivors will have at least one chronic health condition by 40 years of age. Long-term complications concern various organs and systems and have a multifactorial etiopathogenesis. Obesity, diabetes and metabolic syndrome represent chronic diseases that affect life expectancy. Cardiovascular risk partly linked to therapies and genetic susceptibility and partly linked to the presence of obesity, diabetes and metabolic syndrome predispose childhood cancer survivors to heart failure, coronary artery disease, valvular disease, arrhythmia. Hence the cardio- metabolic risk of childhood cancer survivors can have a significant impact on their lives, families, and on society at-large. It is therefore very important to know the risk factors that predispose to the development of cardio-metabolic pathologies in childhood cancer survivors, the possible primary and secondary prevention strategies, the methods of surveillance and the therapeutic approaches.
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Affiliation(s)
- Caterina Luongo
- Department of Woman, Child, General and Specialized Surgery, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Emioli Randazzo
- Department of Clinical and Experimental Medicine, Unit of Pediatric Endocrinology and Diabetes, University of Pisa, Pisa, Italy
| | - Lorenzo Iughetti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Natascia DI Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Sandro Loche
- Pediatric Endocrine Unit, Ospedale Pediatrico Microcitemico A Cao, Cagliari, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuliana Valerio
- Department of Movement Sciences and Wellbeing, University of Naples Parthenope, Naples, Italy
| | - Maurizio Delvecchio
- Metabolic Disorders and Genetic Unit, Giovanni XXIII Children Hospital, Bari, Italy -
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Prus YA, Ansheles AA, Sergienko IV. Effects of Cardioprotective Tactics on the Myocardial Perfusion and Contractile Function of the Left Ventricular Myocardium in Cancer Patients with Evidence of Doxorubicin-Induced Cardiotoxicity. ACTA ACUST UNITED AC 2021; 61:22-27. [PMID: 33734052 DOI: 10.18087/cardio.2021.1.n1376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/24/2020] [Indexed: 11/18/2022]
Abstract
Aim To study the effect of cardioprotective tactics on parameters of left ventricular myocardial perfusion and contractility as per data from single-photon emission computed tomography in oncological patients with signs of anthracycline-induced cardiotoxicity.Material and methods The study included patients with oncological diseases (n=61) referred to polychemotherapy (PCT). For patients with signs of anthracycline-induced cardiotoxicity, a cardioprotective tactics was used, which included changing the PCT schedule and administering beta-blockers and angiotensin-converting enzyme inhibitors. For all patients at baseline, after the first four PCH courses, after initiation of the cardioprotective tactics and the next four PTC courses, the level of N-terminal pro-brain natriuretic peptide was measured and echocardiography and perfusion single-photon emission computed tomography were performed with assessment of left ventricular (LV) perfusion heterogeneity, systolic and diastolic function.Results Following four PTC courses, signs of cardiotoxicity were detected in 13 (21.3 %) patients. On the background of the cardioprotective tactics, a further decrease in LV ejection fraction (EF) by -9±2 % (p<0.01) was observed in 4 (30.8 %) patients. In 9 (69.2 %) patients, LV EF increased by 4±2 % (p<0.01). Standard indexes of LV myocardial perfusion did not significantly change. In 7 patients, the cardioprotective tactics was associated with reduced severity of myocardial perfusion disorder, LV∆σТ = -1.37±1.29 (p<0.05), and in 4 patients, with reduced heterogeneity of myocardial perfusion, LV∆σН = -1.20±0.70 (p<0.05).Conclusion The cardioprotective tactics prevents both further disorder of perfusion and decreases in parameters of left ventricular myocardial contractility in patients with anthracycline-induced cardiotoxicity.
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Affiliation(s)
- Yu A Prus
- National Medical Research Center of Cardiology, Moscow
| | - A A Ansheles
- National Medical Research Center of Cardiology, Moscow
| | - I V Sergienko
- National Medical Research Center of Cardiology, Moscow
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Gupta A, Damania RC, Talati R, O'Riordan MA, Matloub YH, Ahuja SP. Increased Toxicity Among Adolescents and Young Adults Compared with Children Hospitalized with Acute Lymphoblastic Leukemia at Children's Hospitals in the United States. J Adolesc Young Adult Oncol 2021; 10:645-653. [PMID: 33512257 DOI: 10.1089/jayao.2020.0154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Purpose: Adolescent and young adult (AYA) patients (15-39 years old) with acute lymphoblastic leukemia (ALL) have less favorable outcomes and higher treatment-related mortality as compared with older children with ALL. Minimal data exist regarding how well AYA patients tolerate the intensity of chemotherapy at doses and regimens designed for children, and the toxicities suffered by this population at children's hospitals have not been thoroughly characterized. Methods: Pediatric Health Information Systems database was queried to analyze health care outcomes in pediatric (ages 10-14) and AYA patients (ages 15-39) with ALL hospitalized between January 1999 and December 2014. We extracted relevant ICD-9 data for each patient related to grades 3 or 4 toxicities as outlined by the NCI. Results: A total of 5345 hospital admissions met inclusion criteria, representing 4046 unique patients. Of these admissions, 2195 (41.1%) were in the AYA age group, and the remainder were in the 10-14-year-old group. AYA patients had a significantly higher incidence of intensive care unit stay but no difference in median hospital stay nor mortality. AYA patients had increased toxicities in almost every organ system as compared with older children. Conclusions: In this large multicenter US database study, we found an overall increased number of toxicities among AYA patients with ALL in children's hospitals. Compared with children between the ages of 10 and 15, AYA patients developed disproportionately higher toxicities from drugs commonly used in pediatric protocols for ALL. Prospective studies are needed to assess whether dose modifications for certain chemotherapeutics may improve the toxicity profile and health care burden of AYA patients with ALL treated in children's hospitals.
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Affiliation(s)
- Ajay Gupta
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Rahul C Damania
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Ravi Talati
- Division of Hematology, Oncology, and Blood and Marrow Transplant, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Mary Ann O'Riordan
- Women's & Children's Services, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
| | - Yousif H Matloub
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sanjay P Ahuja
- Division of Pediatric Hematology/Oncology, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
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56
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Diagnosis, Prevention, Treatment and Surveillance of Anthracycline-Induced Cardiovascular Toxicity in Pediatric Cancer Survivors. HEARTS 2021. [DOI: 10.3390/hearts2010005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Advances in pediatric cancer therapies have dramatically improved the likelihood of survival. As survivors are aging, however, we are now understanding that treatment carries a significant risk of cardiovascular toxicity, which can develop immediately, or even many years after completing therapy. Anthracycline derivates are some of the most commonly used agents in pediatric oncology treatment protocols, which have a dose-dependent correlation with the development of cardiac toxicity. As we learn more about the mechanisms of toxicity, we are developing prevention strategies, including improvements in surveillance, to improve early diagnosis of heart disease. Current survivorship surveillance protocols often include screening echocardiograms to evaluate systolic function by measuring the ejection fraction or fractional shortening. However, these measurements alone are not enough to capture early myocardial changes. The use of additional imaging biomarkers, serum biomarkers, electrocardiograms, as well as cholesterol and blood pressure screening, are key to the early detection of cardiomyopathy and cardiovascular disease. Medical treatment strategies are the same as those used for heart failure from other causes, but earlier recognition and implementation can lead to improved long term outcomes.
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57
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Liu W, Chen W, Zhang X, Zhao P, Fan Z, Bi L, Wu D, Li S, Yang M, Fu T, Song D, Han B, Zhao G, Du Y, Shi A. Higher efficacy and reduced adverse reactions in neoadjuvant chemotherapy for breast cancer by using pegylated liposomal doxorubicin compared with pirarubicin. Sci Rep 2021; 11:199. [PMID: 33420241 PMCID: PMC7794400 DOI: 10.1038/s41598-020-80415-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 12/21/2020] [Indexed: 12/28/2022] Open
Abstract
The present study aimed to investigate the efficacy and toxicity of pegylated liposomal doxorubicin (PLD) in preoperative neoadjuvant chemotherapy for patients with breast cancer by comparing with conventional anthracycline. This study is a non-randomized controlled trial. Prospective analysis was conducted after matching as required. A total of 146 patients with confirmed diagnosis of breast cancer by histopathological examinations were enrolled into the observation group and control group in 1:1 ratio. Each of the cases in the observation group was required to correspond to another in the control group according to the requirements including age, molecular subtype, axillary node status, and regimen of the preoperative neoadjuvant chemotherapy. The chemotherapy was based on regimens consisting of anthracyclines, paclitaxel or docetaxel, and/or platinum. PLD was used at least twice in the observation group, with traditional anthracycline as a contrast in the control group. Clinical responses as well as cardiac side effects and other adverse reactions were evaluated by clinical and imaging examinations such as electrocardiogram (ECG) and color Doppler ultrasound during the chemotherapy. Pathologic examinations were performed following the surgeries after preoperative neoadjuvant chemotherapy. All the patients in both groups completed the preoperative neoadjuvant chemotherapy according to their original regimens. The postoperative pathological evaluation revealed a higher pathologic complete response (PCR) rate and significantly more patients of grade V of the Miller-Payne grading system in the observation group as compared to the control group (p = 0.047). In addition, the observation group recorded an evidently lower occurrence of the adverse cardiac events (p = 0.014), ECG changes (p = 0.048), and the relatively severe adverse reactions such as myelosuppression. Compared with conventional anthracycline drugs, PLD has a better pathologic response and safety performance, as well as a similar clinical effectiveness in preoperative neoadjuvant chemotherapy for breast cancer.
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Affiliation(s)
- Weifang Liu
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Wei Chen
- Department of Breast Surgery, Song Yuan Central Hospital, Changchun, China
| | - Xiuxiang Zhang
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Peng Zhao
- Department of Thyroid and Breast Surgery, Affiliated Hospital of Jining Medical University, Shandong, China
| | - Zhimin Fan
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Lirong Bi
- Department of Pathology, First Hospital of Jilin University, Changchun, China
| | - Di Wu
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Sijie Li
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Ming Yang
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Tong Fu
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Dong Song
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Bing Han
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Gang Zhao
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Ye Du
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China
| | - Aiping Shi
- Department of Breast Surgery, First Hospital of Jilin University, Changchun, China.
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Cardiotoxicity: A Major Setback in Childhood Leukemia Treatment. DISEASE MARKERS 2021; 2021:8828410. [PMID: 33505537 PMCID: PMC7810535 DOI: 10.1155/2021/8828410] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/15/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023]
Abstract
Ongoing research in the field of pediatric oncology has led to an increased number of childhood cancer survivors reaching adulthood. Therefore, ensuring a good quality of life for these patients has become a rising priority. Considering this, the following review focuses on summarizing the most recent research in anthracycline-induced cardiac toxicity in children treated for leukemia. For pediatric cancers, anthracyclines are one of the most used anticancer drugs, with over half of the childhood cancer survivors believed to have been exposed to them. Anthracyclines cause irreversible cardiomyocyte loss, leading to chronic, progressive heart failure. The risk of developing cardiotoxicity has been known to increase with the treatment-free interval and total cumulative dose. However, because of individual variations in anthracycline metabolism, it has recently been shown that there is no risk-free dose. Moreover, studies have shown that diagnosing anthracycline-induced cardiomyopathy in the symptomatic phase is associated with poor treatment response and prognosis. Thus, early and systematic evaluation of these patients is crucial to allow optimal therapeutic intervention. Although currently echocardiographic assessment of left ventricle ejection fraction and cardiac biomarker evaluation are being used for cardiac function monitoring in oncologic patients, there is no established follow-up and treatment protocol for these patients, and these methods are neither specific nor sensitive for identifying early cardiac dysfunction. All things considered, the need for ongoing research in the field of pediatric cardiooncology is crucial to offer these patients a chance at a good quality of life as adults.
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59
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Iacopo F, Branch M, Cardinale D, Middeldorp M, Sanders P, Cohen JB, Achirica MC, Jaiswal S, Brown SA. Preventive Cardio-Oncology: Cardiovascular Disease Prevention in Cancer Patients and Survivors. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00883-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Li L, Nie X, Zhang P, Huang Y, Ma L, Li F, Yi M, Qin W, Yuan X. Dexrazoxane ameliorates radiation-induced heart disease in a rat model. Aging (Albany NY) 2021; 13:3699-3711. [PMID: 33406500 PMCID: PMC7906151 DOI: 10.18632/aging.202332] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/03/2020] [Indexed: 12/13/2022]
Abstract
Treatment of thoracic tumors with radiotherapy can lead to severe cardiac injury. We investigated the effects of dexrazoxane, a USFDA-approved cardioprotective drug administered with chemotherapy, on radiation-induced heart disease (RIHD) in a rat model. Male Sprague-Dawley rats were irradiated with a single dose of 20 Gy to the heart and treated with dexrazoxane at the time of irradiation and for 12 subsequent weeks. Dexrazoxane suppressed radiation-induced myocardial apoptosis and significantly reversed changes in serum cardiac troponin I levels and histopathological characteristics six months post-radiation. Treatment with dexrazoxane did not alter the radiosensitivity of thoracic tumors in a tumor formation experiment using male nude Balb/C mice with tumors generated by H292 cells. Dexrazoxane reduced the accumulation of reactive oxygen species in rat cardiac tissues, but not in tumors in nude mice. Transcriptome sequencing showed that IKBKE, MAP3K8, NFKBIA, and TLR5, which are involved in Toll-like receptor signaling, may be associated with the anti-RIHD effects of dexrazoxane. Immunohistochemistry revealed that dexrazoxane significantly decreased NF-κB p65 expression in cardiomyocytes. These findings suggest dexrazoxane may protect against RIHD by suppressing apoptosis and oxidative stress in cardiomyocytes.
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Affiliation(s)
- Long Li
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Xiaoqi Nie
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Peng Zhang
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yongbiao Huang
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Li Ma
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Fang Li
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Minxiao Yi
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Wan Qin
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Xianglin Yuan
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
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61
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Tantawy M, Pamittan FG, Singh S, Gong Y. Epigenetic Changes Associated With Anthracycline-Induced Cardiotoxicity. Clin Transl Sci 2021; 14:36-46. [PMID: 32770710 PMCID: PMC7877852 DOI: 10.1111/cts.12857] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 07/11/2020] [Indexed: 12/24/2022] Open
Abstract
Advances in cancer treatment have significantly improved the survival of patients with cancer, but, unfortunately, many of these treatments also have long-term complications. Cancer treatment-related cardiotoxicities are becoming a significant clinical problem that a new discipline, Cardio-Oncology, was established to advance the cardiovascular care of patients with growing cancer populations. Anthracyclines are a class of chemotherapeutic agents used to treat many cancers in adults and children. Their clinical use is limited by anthracycline-induced cardiotoxicity (AIC), which can lead to heart failure. Early-onset cardiotoxicity appears within a year of treatment, whereas late-onset cardiotoxicity occurs > 1 year and even up to decades after treatment completion. The pathophysiology of AIC was hypothesized to be caused by generation of reactive oxygen species that lead to lipid peroxidation, defective mitochondrial biogenesis, and DNA damage of the cardiomyocytes. The accumulation of anthracycline metabolites was also proposed to cause mitochondrial damage and the induction of cardiac cell apoptosis, which induces arrhythmias, contractile dysfunction, and cardiomyocyte death. This paper will provide a general overview of cardiotoxicity focusing on the effect of anthracyclines and their epigenetic molecular mechanisms on cardiotoxicity.
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Affiliation(s)
- Marwa Tantawy
- Department of Pharmacotherapy and Translational ResearchCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- Center for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Frances G. Pamittan
- Department of Pharmacotherapy and Translational ResearchCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | | | - Yan Gong
- Department of Pharmacotherapy and Translational ResearchCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- Center for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- UF Health Cancer CenterGainesvilleFloridaUSA
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Abstract
Cardio-Oncology has blossomed as a new field in cardiovascular medicine, in large part due to new therapies, which may have cardiovascular sequelae. Despite this, anthracyclines still serve as cornerstone therapy for most pediatric cancers, several solid tumors and hematological malignancies. Cardiotoxicity is the main limiting concern with anthracyclines, and this is particularly an issue in patients in extremes of age (both young and old patients). Pediatric hearts are susceptible for cardiotoxicity, while in older patients, concomitant risk factors may contribute to lower threshold for cardiotoxic effects. With increasing patient survival, a significant increase in elderly cancer patients and long-term cardiotoxicity effects of anthracyclines, a better mechanistic understanding of age-dependent processes-that define cardiotoxicity-is needed. This review sheds light on how age affects underlying molecular pathways of anthracycline-associated cardiotoxicity and aims to provide preventive strategies that can be used in clinical practice.
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Affiliation(s)
- Elles M Screever
- Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wouter C Meijers
- Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Javid J Moslehi
- Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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Trapani D, Zagami P, Nicolò E, Pravettoni G, Curigliano G. Management of Cardiac Toxicity Induced by Chemotherapy. J Clin Med 2020; 9:E2885. [PMID: 32906611 PMCID: PMC7565686 DOI: 10.3390/jcm9092885] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 01/11/2023] Open
Abstract
Cardiotoxicity encompasses a spectrum of adverse cardiological effects experienced by cancer patients during and after receiving antineoplastic treatments. The intersection of cancer care with the management of the multiple comorbid non-communicable diseases carried by patients or related to cancer treatments motivates the need for an integrated and multidisciplinary approach to therapeutic clinical decision-making. This present review aimed to provide a perspective and an update of the current pharmacotherapy approaches for the prevention and management of cardiotoxicity from antiblastic chemotherapy; as such, it addresses myocardial, vascular, and arrhythmic disorders associated to chemotherapy, by navigating the current knowledge and clinical indications in support of the medical interventions. Clinical scenarios of pharmacological interventions take place with patients receiving anthracycline and, by extrapolation, other agents with cardiotoxic potentials and non-chemotherapy agents, including various small molecules and immunotherapy agents. Analysis of these scenarios aims to provide practical evidence-based guidance for the management of drug-induced cardiac dysfunctions. The possible role of new biomarkers for the early recognition of cardiotoxicity is mentioned across the clinical studies, with reference to the pharmacological biomarker-driven interventions delivered. To best inform survivorship care, the management and context of cardio-oncology services are discussed within the broader network of providers and settings of care.
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Affiliation(s)
- Dario Trapani
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; (D.T.); (P.Z.); (E.N.); (G.P.)
| | - Paola Zagami
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; (D.T.); (P.Z.); (E.N.); (G.P.)
- Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Eleonora Nicolò
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; (D.T.); (P.Z.); (E.N.); (G.P.)
- Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Gabriella Pravettoni
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; (D.T.); (P.Z.); (E.N.); (G.P.)
- Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Giuseppe Curigliano
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; (D.T.); (P.Z.); (E.N.); (G.P.)
- Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
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Leerink JM, de Baat EC, Feijen EA, Bellersen L, van Dalen EC, Grotenhuis HB, Kapusta L, Kok WE, Loonen J, van der Pal HJ, Pluijm SM, Teske AJ, Mavinkurve-Groothuis AM, Merkx R, Kremer LC. Cardiac Disease in Childhood Cancer Survivors: Risk Prediction, Prevention, and Surveillance: JACC CardioOncology State-of-the-Art Review. JACC CardioOncol 2020; 2:363-378. [PMID: 34396245 PMCID: PMC8352294 DOI: 10.1016/j.jaccao.2020.08.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023] Open
Abstract
Cardiac diseases in the growing population of childhood cancer survivors are of major concern. Cardiotoxicity as a consequence of anthracyclines and chest radiotherapy continues to be relevant in the modern treatment era. Mitoxantrone has emerged as an important treatment-related risk factor and evidence on traditional cardiovascular risk factors in childhood cancer survivors is accumulating. International surveillance guidelines have been developed with the aim to detect and manage cardiac diseases early and prevent symptomatic disease. There is growing interest in risk prediction models to individualize prevention and surveillance. This State-of-the-Art Review summarizes literature from a systematic PubMed search focused on cardiac diseases after treatment for childhood cancer. Here, we discuss the prevalence, risk factors, prevention, risk prediction, and surveillance of cardiac diseases in survivors of childhood cancer.
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Key Words
- CAD, coronary artery disease
- CCS, childhood cancer survivors
- ECG, electrocardiogram
- FS, fractional shortening
- GLS, global longitudinal strain
- IGHG, International Late Effects of Childhood Cancer Guideline Harmonization Group
- LV, left ventricle
- LVEF, left ventricular ejection fraction
- RCT, randomized controlled trial
- cardiotoxicity
- cardiovascular risk factors
- chest RT, chest-directed radiotherapy
- childhood cancer survivors
- prevention
- risk prediction
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Affiliation(s)
- Jan M. Leerink
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Esmée C. de Baat
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | | | - Louise Bellersen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elvira C. van Dalen
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University of Utrecht, Utrecht, the Netherlands
| | - Livia Kapusta
- Department of Pediatric Cardiology, Radboud University Medical Center, Amalia Children’s Hospital, Nijmegen, the Netherlands
- Department of Pediatrics, Tel Aviv University, Sackler School of Medicine, Tel Aviv Sourasky Medical Center, Pediatric Cardiology Unit, Tel Aviv, Israel
| | - Wouter E.M. Kok
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Jacqueline Loonen
- Department of Pediatric Hematology and Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Saskia M.F. Pluijm
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | - Arco J. Teske
- Department of Cardiology, Utrecht University Medical Center, Utrecht, the Netherlands
| | | | - Remy Merkx
- Department of Medical Imaging, Radboud University Medical Center, Medical UltraSound Imaging Center, Nijmegen, the Netherlands
| | - Leontien C.M. Kremer
- Department of Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
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Childhood cancer survivors: The integral role of the cardiologist and cardiovascular imaging. Am Heart J 2020; 226:127-139. [PMID: 32531502 DOI: 10.1016/j.ahj.2020.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/06/2020] [Indexed: 12/18/2022]
Abstract
IMPORTANCE With 80% of childhood cancer survivors (CCS) alive 30 years after diagnosis, preventable causes of death, such as cardiovascular disease resulting from initial cancer therapy, becomes an important metric. This leads to a more pronounced role for cardiologists in the care of CCS. OBSERVATIONS While routine cardiovascular screening has been traditionally performed by the hematologist/oncologist or primary care provider, our understanding of cardiovascular disease in CCS has advanced. The measurement of left ventricular ejection fraction (LVEF) can now be complemented with additional assessments of strain, LV mass, right ventricular function, diastolic function, valve function, the pericardium, coronary perfusion, and biomarkers. Risk factor modification, prophylaxis, and timing of treatment are also critical. CONCLUSIONS AND RELEVANCE Early cardiovascular screening and treatment in asymptomatic CCS can be nuanced and complex. As a result, there is a renewed opportunity for the cardiologist to play an integral role in the care of CCS. KEY POINTS Question/Purpose: Review cardiovascular disease and the role of the cardiologist in the care of asymptomatic childhood cancer survivors (CCS). FINDINGS Cardiovascular care in CCS benefits from a multi-faceted approach that does not overly rely on LVEF. Meaning: Adequate screening and treatment of cardiovascular disease in asymptomatic CCS may often be optimized by the involvement of a cardiologist.
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66
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Upshaw JN. Cardioprotective Strategies to Prevent Cancer Treatment-Related Cardiovascular Toxicity: a Review. Curr Oncol Rep 2020; 22:72. [DOI: 10.1007/s11912-020-00923-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Barach P, Lipshultz SE. Rethinking COVID-19 in children: Lessons learned from pediatric viral and inflammatory cardiovascular diseases. PROGRESS IN PEDIATRIC CARDIOLOGY 2020; 57:101233. [PMID: 32837143 PMCID: PMC7243773 DOI: 10.1016/j.ppedcard.2020.101233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Paul Barach
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, United States of America
- Jefferson College of Population Health, Philadelphia, PA, United States of America
| | - Steven E Lipshultz
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States of America
- Oishei Children's Hospital, Buffalo, NY, United States of America
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States of America
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68
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Raber I, Asnani A. Cardioprotection in cancer therapy: novel insights with anthracyclines. Cardiovasc Res 2020; 115:915-921. [PMID: 30726931 DOI: 10.1093/cvr/cvz023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/12/2018] [Accepted: 01/25/2019] [Indexed: 12/23/2022] Open
Abstract
Anthracyclines are a class of antineoplastic agents that remain critical to modern-day cancer treatment. However, their propensity to cause cardiotoxic effects limits their use and can cause increased morbidity and mortality among patients with cancer. Currently available methods to minimize the impact of anthracycline cardiotoxicity have not been widely successful. While it is largely accepted that the generation of oxygen radicals contributes to the development of anthracycline cardiotoxicity, the exact mechanisms of cardiomyocyte injury remain unclear. In this review, we discuss the current state of basic and translational research on the cardiotoxic mechanisms of anthracyclines that have led to the discovery of new therapeutic targets. Pending validation in patient populations, these recent advances have the potential to be translated into clinical approaches that will minimize anthracycline cardiotoxicity and improve outcomes in cancer survivors.
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Affiliation(s)
- Inbar Raber
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Aarti Asnani
- Harvard Medical School, Boston, MA, USA.,CardioVascular Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
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69
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Getz KD, Sung L, Alonzo TA, Leger KJ, Gerbing RB, Pollard JA, Cooper T, Kolb EA, Gamis AS, Ky B, Aplenc R. Effect of Dexrazoxane on Left Ventricular Systolic Function and Treatment Outcomes in Patients With Acute Myeloid Leukemia: A Report From the Children's Oncology Group. J Clin Oncol 2020; 38:2398-2406. [PMID: 32343641 DOI: 10.1200/jco.19.02856] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To determine whether dexrazoxane provides effective cardioprotection during frontline treatment of pediatric acute myeloid leukemia (AML) without increasing relapse risk or noncardiac toxicities of the chemotherapy regimens. PATIENTS AND METHODS This was a multicenter study of all pediatric patients with AML without high allelic ratio FLT3/ITD treated in the Children's Oncology Group trial AAML1031 between 2011 and 2016. Median follow-up was 3.5 years. Dexrazoxane was administered at the discretion of treating physicians and documented at each course. Ejection fraction (EF) and shortening fraction (SF) were recorded after each course and at regular intervals in follow-up. Per protocol, anthracyclines were to be withheld if there was evidence of left ventricular systolic dysfunction (LVSD) defined as SF < 28% or EF < 55%. Occurrence of LVSD, trends in EF and SF, 5-year event-free survival (EFS) and overall survival (OS), and treatment-related mortality (TRM) were compared by dexrazoxane exposure. RESULTS A total of 1,014 patients were included in the analyses; 96 were exposed to dexrazoxane at every anthracycline course, and 918 were never exposed. Distributions of sex, age, race, presenting WBC count, risk group, treatment arm, and compliance with cardiac monitoring were similar for dexrazoxane-exposed and -unexposed patients. Dexrazoxane-exposed patients had significantly smaller EF and SF declines than unexposed patients across courses and a lower risk for LVSD (26.5% v 42.2%; hazard ratio, 0.55; 95% CI, 0.36 to 0.86; P = .009). Dexrazoxane-exposed patients had similar 5-year EFS (49.0% v 45.1%; P = .534) and OS (65.0% v 61.9%; P = .613) to those unexposed; however, there was a suggestion of lower TRM with dexrazoxane (5.7% v 12.7%; P = .068). CONCLUSION Dexrazoxane preserved cardiac function without compromising EFS and OS or increasing noncardiac toxicities. Dexrazoxane should be considered for cardioprotection during frontline treatment of pediatric AML.
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Affiliation(s)
- Kelly D Getz
- Children's Hospital of Philadelphia, Philadelphia, PA.,University of Pennsylvania, Philadelphia, PA
| | - Lillian Sung
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | - Jessica A Pollard
- Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | - E Anders Kolb
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Alan S Gamis
- Children's Mercy Hospital and Clinics, Kansas City, MO
| | - Bonnie Ky
- University of Pennsylvania, Philadelphia, PA
| | - Richard Aplenc
- Children's Hospital of Philadelphia, Philadelphia, PA.,University of Pennsylvania, Philadelphia, PA
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70
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Schwach V, Slaats RH, Passier R. Human Pluripotent Stem Cell-Derived Cardiomyocytes for Assessment of Anticancer Drug-Induced Cardiotoxicity. Front Cardiovasc Med 2020; 7:50. [PMID: 32322588 PMCID: PMC7156610 DOI: 10.3389/fcvm.2020.00050] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/16/2020] [Indexed: 12/26/2022] Open
Abstract
Cardiotoxicity is a major cause of high attrition rates among newly developed drugs. Moreover, anti-cancer treatment-induced cardiotoxicity is one of the leading reasons of mortality in cancer survivors. Cardiotoxicity screening in vitro may improve predictivity of cardiotoxicity by novel drugs, using human pluripotent stem cell (hPSC)-derived-cardiomyocytes. Anthracyclines, including Doxorubicin, are widely used and highly effective chemotherapeutic agents for the treatment of different forms of malignancies. Unfortunately, anthracyclines cause many cardiac complications early or late after therapy. Anthracyclines exhibit their potent anti-cancer effect primarily via induction of DNA damage during the DNA replication phase in proliferative cells. In contrast, studies in animals and hPSC-cardiomyocytes have revealed that cardiotoxic effects particularly arise from (1) the generation of oxidative stress inducing mitochondrial dysfunction, (2) disruption of calcium homeostasis, and (3) changes in transcriptome and proteome, triggering apoptotic cell death. To increase the therapeutic index of chemotherapeutic Doxorubicin therapy several protective strategies have been developed or are under development, such as (1) reducing toxicity through modification of Doxorubicin (analogs), (2) targeted delivery of anthracyclines specifically to the tumor tissue or (3) cardioprotective agents that can be used in combination with Doxorubicin. Despite continuous progress in the field of cardio-oncology, cardiotoxicity is still one of the major complications of anti-cancer therapy. In this review, we focus on current hPSC-cardiomyocyte models for assessing anthracycline-induced cardiotoxicity and strategies for cardioprotection. In addition, we discuss latest developments toward personalized advanced pre-clinical models that are more closely recapitulating the human heart, which are necessary to support in vitro screening platforms with higher predictivity. These advanced models have the potential to reduce the time from bench-to-bedside of novel antineoplastic drugs with reduced cardiotoxicity.
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Affiliation(s)
- Verena Schwach
- Applied Stem Cell Technologies, TechMed Centre, University of Twente, Enschede, Netherlands
| | - Rolf H Slaats
- Applied Stem Cell Technologies, TechMed Centre, University of Twente, Enschede, Netherlands
| | - Robert Passier
- Applied Stem Cell Technologies, TechMed Centre, University of Twente, Enschede, Netherlands.,Department of Anatomy and Embryology, Leiden University Medical Centre, Leiden, Netherlands
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71
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Cardinale D, Iacopo F, Cipolla CM. Cardiotoxicity of Anthracyclines. Front Cardiovasc Med 2020; 7:26. [PMID: 32258060 PMCID: PMC7093379 DOI: 10.3389/fcvm.2020.00026] [Citation(s) in RCA: 204] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/18/2020] [Indexed: 12/12/2022] Open
Abstract
Cardiotoxicity is a feared side effect that may limit the clinical use of anthracyclines. It may indeed affect the quality of life and survival of patients with cancer, regardless of oncological prognosis. This paper provides an overview of anthracycline-induced cardiotoxicity in terms of definition, classification, incidence, risk factors, possible mechanisms, diagnosis, and treatment. We also report effective strategies for preventing cardiotoxicity. In addition, we discuss limiting current approaches, the need for a new classification, and early cardiotoxicity detection and treatment. Probably, anthracycline-induced cardiotoxicity is a continuous phenomenon that starts from myocardial cell injury; it is followed by left ventricular ejection fraction (LVEF) and, if not diagnosed and cured early, progressively leads to symptomatic heart failure. Anthracycline-induced cardiotoxicity can be detected at a preclinical phase. The role of biomarkers, in particular troponins, in identifying subclinical cardiotoxicity and its therapy with angiotensin-converting enzyme inhibitors (mainly enalapril) to prevent LVEF reduction is a recognized and effective strategy. If cardiac dysfunction has already occurred, partial or complete LVEF recovery may still be obtained in case of early detection of cardiotoxicity and prompt heart failure treatment.
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Affiliation(s)
- Daniela Cardinale
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | - Fabiani Iacopo
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
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72
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Murabito A, Hirsch E, Ghigo A. Mechanisms of Anthracycline-Induced Cardiotoxicity: Is Mitochondrial Dysfunction the Answer? Front Cardiovasc Med 2020; 7:35. [PMID: 32226791 PMCID: PMC7080657 DOI: 10.3389/fcvm.2020.00035] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/24/2020] [Indexed: 12/19/2022] Open
Abstract
Cardiac side effects are a major drawback of anticancer therapies, often requiring the use of low and less effective doses or even discontinuation of the drug. Among all the drugs known to cause severe cardiotoxicity are anthracyclines that, though being the oldest chemotherapeutic drugs, are still a mainstay in the treatment of solid and hematological tumors. The recent expansion of the field of Cardio-Oncology, a branch of cardiology dealing with prevention or treatment of heart complications due to cancer treatment, has greatly improved our knowledge of the molecular mechanisms behind anthracycline-induced cardiotoxicity (AIC). Despite excessive generation of reactive oxygen species was originally believed to be the main cause of AIC, recent evidence points to the involvement of a plethora of different mechanisms that, interestingly, mainly converge on deregulation of mitochondrial function. In this review, we will describe how anthracyclines affect cardiac mitochondria and how these organelles contribute to AIC. Furthermore, we will discuss how drugs specifically targeting mitochondrial dysfunction and/or mitochondria-targeted drugs could be therapeutically exploited to treat AIC.
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Affiliation(s)
- Alessandra Murabito
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Turin, Turin, Italy
| | - Emilio Hirsch
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Turin, Turin, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Turin, Turin, Italy
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73
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Abstract
Anthracycline-associated cardiomyopathy and peripartum cardiomyopathy are nonischemic cardiomyopathies that often afflict previously healthy young patients; both diseases have been well described since at least the 1970s and both occur in the settings of predictable stressors (ie, cancer treatment and pregnancy). Despite this, the precise mechanisms and the ability to reliably predict who exactly will go on to develop cardiomyopathy and heart failure in the face of anthracycline exposure or childbirth have proven elusive. For both cardiomyopathies, recent advances in basic and molecular sciences have illuminated the complex balance between cardiomyocyte and endothelial homeostasis via 3 broad pathways: reactive oxidative stress, interference in apoptosis/growth/metabolism, and angiogenic imbalance. These advances have already shown potential for specific, disease-altering therapies, and as our mechanistic knowledge continues to evolve, further clinical successes are expected to follow.
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Affiliation(s)
- Joshua A Cowgill
- From the Department of Cardiovascular Medicine, Maine Medical Center, Portland
| | - Sanjeev A Francis
- From the Department of Cardiovascular Medicine, Maine Medical Center, Portland
| | - Douglas B Sawyer
- From the Department of Cardiovascular Medicine, Maine Medical Center, Portland
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74
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Ketterl TG, Latham GJ. Perioperative Cardiothoracic and Vascular Risk in Childhood Cancer and its Survivors. J Cardiothorac Vasc Anesth 2020; 35:162-175. [PMID: 32360009 DOI: 10.1053/j.jvca.2020.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/11/2020] [Accepted: 02/28/2020] [Indexed: 11/11/2022]
Abstract
CHILDREN with cancer and survivors of childhood cancer have an increased risk of cardiovascular disease, and this risk in the perioperative period must be understood. During diagnosis and treatment of pediatric cancer, multiple acute cardiovascular morbidities are possible, including anterior mediastinal mass, tamponade, hypertension, cardiomyopathy,and heart failure. Childhood cancer survivors reaching late childhood and adulthood experience substantially increased rates of cardiomyopathy, heart failure, valvular disease, pericardiac disease, ischemia, and arrhythmias. Despite considerable advances in the understanding and therapeutic options of pediatric malignancies, cardiac disease remains the most common treatment-related, noncancer cause of death in childhood cancer survivors. Increasingly, molecularly targeted agents, including small molecule inhibitors, are being incorporated into pediatric oncology. The acute and chronic risks associated with these newer therapeutic options in children are not yet well-described, which poses challenges for clinicians caring for these patients. In the present review, the unique risks factors, prevention strategies, and treatment of cardiovascular toxicities of the child with cancer and the childhood cancer survivor are examined, with an emphasis on the perioperative period.
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Affiliation(s)
- Tyler G Ketterl
- Department of Pediatric Hematology and Oncology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
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75
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Abstract
Anthracyclines have proved to be one of the most effective chemotherapeutic agents in the treatment of numerous solid tumors and hematologic malignancies in both adult and pediatric patients. Their clinical benefit, however, is sometimes hampered by the development of cardiotoxicity, a process that still remains elusive despite decades of investigation. It has been postulated that anthracycline-induced cardiotoxicity is mediated in part by reactive oxygen species and redox cycling. This article reviews anthracycline cardiotoxicity in terms of historical significance, epidemiology, current detection strategies, prevention strategies, and patient care after anthracycline-based chemotherapy.
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76
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Dewilde S, Carroll K, Nivelle E, Sawyer J. Evaluation of the cost-effectiveness of dexrazoxane for the prevention of anthracycline-related cardiotoxicity in children with sarcoma and haematologic malignancies: a European perspective. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:7. [PMID: 32063753 PMCID: PMC7011276 DOI: 10.1186/s12962-020-0205-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/04/2020] [Indexed: 12/18/2022] Open
Abstract
Background Anthracycline-treated childhood cancer survivors are at higher risk of cardiotoxicity, especially with cumulative doses received above 250 mg/m2. Dexrazoxane is the only option recommended for cardiotoxicity prevention in high-risk patients supported by randomised trials but its cost-effectiveness in paediatric cancer patients has not been established. Methods A cost-effectiveness model applicable to different national healthcare system perspectives, which simulates 10,000 patients with either sarcoma or haematologic malignancies, based upon baseline characteristics including gender, age at diagnosis, cumulative anthracycline dose and exposure to chest irradiation. Risk equations for developing congestive heart failure and death from recurrence of the original cancer, secondary malignant neoplasms, cardiac death, pulmonary death, and death from other causes were derived from published literature. These are applied to the individual simulated patients and time until development of these events was determined. The treatment effect of dexrazoxane on the risk of CHF or death was based upon a meta-analysis of randomised and non-randomised dexrazoxane studies in each tumour type. The model includes country specific data for drug and administration costs, all aspects of heart failure diagnosis and management, and death due to different causes for each of the five countries considered; France, Germany, the UK, Italy, and Spain. Results Dexrazoxane treatment resulted in a mean QALY benefit across the five countries ranging from 0.530 to 0.683 per dexrazoxane-treated patient. Dexrazoxane was cost-effective for paediatric patients receiving anthracycline treatment for sarcoma and for haematologic malignancies, irrespective of the cumulative anthracycline dose received. The Incremental Cost Effectiveness Ratio (ICER) was favourable in all countries irrespective of anthracycline dose for both sarcoma and haematological malignancies (range: dominant to €2196). Individual ICER varied considerably according to country with dominance demonstrated for dexrazoxane in Spain and Italy and ratios approximately double the European average in the UK and Germany. Conclusions Dexrazoxane is a highly cost-effective therapy for the prevention of anthracycline cardiotoxicity in paediatric patients with sarcoma or haematological malignancies in Europe, irrespective of the healthcare system in which they receive treatment. These benefits persist when patients who receive doses of anthracycline > 250 mg/m2 are included in the model.
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Affiliation(s)
| | | | | | - James Sawyer
- Prism Ideas Ltd, Morston House, Beam Heath Way, Nantwich, CW5 6GD UK
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77
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Ashrafizadeh M, Ahmadi Z, Samarghandian S, Mohammadinejad R, Yaribeygi H, Sathyapalan T, Sahebkar A. MicroRNA-mediated regulation of Nrf2 signaling pathway: Implications in disease therapy and protection against oxidative stress. Life Sci 2020; 244:117329. [PMID: 31954747 DOI: 10.1016/j.lfs.2020.117329] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/12/2020] [Accepted: 01/15/2020] [Indexed: 12/15/2022]
Abstract
MicroRNAs (miRs) are small non-coding pieces of RNA that are involved in a variety of physiologic processes such as apoptosis, cell proliferation, cell differentiation, cell cycle and cell survival. These multifunctional nucleotides are also capable of preventing oxidative damages by modulating antioxidant defense systems in a variety of milieu, such as in diabetes. Although the exact molecular mechanisms by which miRs modulate the antioxidant defense elements are unclear, some evidence suggests that they may exert these effects via nuclear factor erythroid 2-related factor 2 (Nrf2) signaling pathway. This intracellular mechanism is crucial in the maintenance of the physiologic redox balance by regulating the expression and activity of various cellular antioxidative defense elements and thereby plays a pivotal role in the development of oxidative stress. Any impairment in the Nrf2 signaling pathway may result in oxidative damage-dependent complications such as various diabetic complications, neurological disorders and cancer. In the current review, we discuss the modulatory effects of miRs on the Nrf2 signaling pathway, which can potentially be novel therapeutic targets.
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Affiliation(s)
- Milad Ashrafizadeh
- Department of Basic Science, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran
| | - Zahra Ahmadi
- Department of Basic Science, Shoushtar Branch, Islamic Azad University, Shoushtar, Iran
| | - Saeed Samarghandian
- Department of Basic Medical Sciences, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | - Reza Mohammadinejad
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Habib Yaribeygi
- Research Center of Physiology, Semnan University of Medical Sciences, Semnan, Iran.
| | - Thozhukat Sathyapalan
- Department of Academic Diabetes, Endocrinology and Metabolism, Hull York Medical School, University of Hull, Hull, UK
| | - Amirhossein Sahebkar
- Halal Research Center of IRI, FDA, Tehran, Iran; Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Brown SA. Preventive Cardio-Oncology: The Time Has Come. Front Cardiovasc Med 2020; 6:187. [PMID: 31998754 PMCID: PMC6965025 DOI: 10.3389/fcvm.2019.00187] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/10/2019] [Indexed: 12/17/2022] Open
Affiliation(s)
- Sherry-Ann Brown
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
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79
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Li J, Chang HM, Banchs J, Araujo DM, Hassan SA, Wagar EA, Yeh ETH, Meng QH. Detection of subclinical cardiotoxicity in sarcoma patients receiving continuous doxorubicin infusion or pre-treatment with dexrazoxane before bolus doxorubicin. CARDIO-ONCOLOGY 2020; 6:1. [PMID: 32154027 PMCID: PMC7048030 DOI: 10.1186/s40959-019-0056-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/28/2019] [Indexed: 12/03/2022]
Abstract
Background Continuous infusion of doxorubicin or dexrazoxane pre-treatment prior to bolus doxorubicin are proven strategies to protect against doxorubicin-induced cardiotoxicity. Recently, global longitudinal peak systolic strain (GLS) measured with speckle tracking echocardiography (STE) and high-sensitivity troponin T (hs-TnT) have been validated as sensitive indicators of doxorubicin-induced cardiotoxicity. Here, we asked whether changes in hs-TnT and/or GLS can be detected in patients who were treated with continuous infusion of doxorubicin or pre-treated with dexrazoxane followed by bolus doxorubicin. Methods Twenty-nine patients with newly diagnosed sarcoma were assigned to receive either 72-h doxorubicin infusion or dexrazoxane pre-treatment before bolus doxorubicin. Eight patients received dexrazoxane pre-treatment; eleven patients received continuous doxorubicin infusion; ten patients crossed over from continuous infusion to dexrazoxane. Bloods were collected for hs-TnT at baseline, 24 h or 72 h after initiation of doxorubicin treatment in each chemotherapy cycle. All blood samples were assayed in batch using hs-TnT kit from Roche diagnostics. 2D Echo and STE were performed before doxorubicin, after cycle 3, and at the end of chemotherapy. Results Seven patients in the cross-over group have at least one hs-TnT measurement between 5 ng/L to 10 ng/L during and after chemotherapy. Ten patients have at least one hs-TnT measurement above 10 ng/ml during and after chemotherapy (six in dexrazoxane group, three in continuous infusion group, one in cross-over group). The average hs-TnT level increases with each additional cycle of doxorubicin treatment. Eight patients had a more than 5% reduction in LVEF at the end of chemotherapy (four in dexrazoxane group, three in continuous infusion group, and one in cross-over group). Four out of these eight patients had a change of GLS by more than 15% (three in the dexrazoxane group). Conclusion Elevation in hs-TnT levels were observed in more than 59% of patients who had received either continuous doxorubicin infusion or dexrazoxane pre-treatment before bolus doxorubicin. However, changes in LVEF and GLS were less frequently observed. Thus, continuous doxorubicin infusion or dexrazoxane pre-treatment do not completely ameliorate subclinical doxorubicin-induced cardiotoxicity as detected by more sensitive techniques.
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Affiliation(s)
- Jieli Li
- 1Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Hui-Ming Chang
- 2Center for Precision Medicine, Department of Medicine, University of Missouri School of Medicine, Columbia, MO USA
| | - Jose Banchs
- 3Departments of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Dejka M Araujo
- 4Department of Sarcoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Saamir A Hassan
- 3Departments of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Elizabeth A Wagar
- 1Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Edward T H Yeh
- 2Center for Precision Medicine, Department of Medicine, University of Missouri School of Medicine, Columbia, MO USA
| | - Qing H Meng
- 1Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX USA
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Ribeiro ILA, Melo ACRD, Limão NP, Bonan PRF, Lima Neto EDA, Valença AMG. Oral Mucositis in Pediatric Oncology Patients: A Nested Case-Control to a Prospective Cohort. Braz Dent J 2020; 31:78-88. [DOI: 10.1590/0103-6440201802881] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/06/2019] [Indexed: 11/21/2022] Open
Abstract
Abstract This study aimed to evaluate the factors associated with the occurrence of severe oral mucositis (SOM) in pediatric oncology patients during the chemotherapeutic treatment. This is a nested case-control to a prospective cohort that monitored 105 patients for 10 consecutive weeks after the beginning of the chemotherapy treatment. Logistic regression was used to identify the factors associated with SOM, by group of malignancy (hematologic or solid tumors) (Sig.=5%). To patients with hematologic tumors were found factors associated with SOM in two weeks of treatment: in the 6th week (increase in frequency of chemotherapy doses (OR=3.02)) and in the 7th week (female sex (OR=21.28); and increase in frequency of chemotherapy doses (OR=2.51)); and to patients with solid tumors were found factors associated with SOM in five weeks of treatment: in the 1st week (female sex (OR=14.43); age increase (OR=1.24)); in the 2nd week (Miscellany (OR=6.39)); in the 5th week (Antimetabolites (OR=17.44); Miscellany (OR=45.42); and platelets reduction (OR=1.12)); in the 6th week (creatinine increase (OR=1.63)); and in the 7th week (creatinine increase (OR=2.39)). For patients with hematologic tumors, to be female, and the increase in the frequency of chemotherapy doses increased the risk for SOM and for patients with solid tumors, to be female, the increase in age and in level blood concentration of creatinine, the reduction in number of platelets and the use of chemotherapy with miscellany and antimetabolites agents were associated with an increase in risk for occurrence of SOM.
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81
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Hempel G. Pharmacotherapy in Children and Adolescents: Oncology. Handb Exp Pharmacol 2020; 261:415-440. [PMID: 31792677 DOI: 10.1007/164_2019_306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pharmacotherapy in paediatric oncology is a difficult task. It is challenging to determine the optimal dose in children of different age groups. In addition, anticancer drugs display severe side effects reducing the quality of life. Late effects like secondary tumours and cardiotoxicity can be apparent years after treatment and must be taken into account when planning treatment schedules. Classical cytoreducing agents are still of great importance in treating children with leukaemia and solid tumours. In addition, drugs developed by rational drug design (targeted drugs) are a very important part of many treatment protocols, and newer drugs are emerging in several types of cancer. Unfortunately, there is only limited experience with newer drugs in children, because new drugs are mostly developed for adults. Complicated therapy regimens require a solid knowledge of the pharmacology of the drugs applied. This chapter attempts to introduce some pharmacological knowledge for the most important anticancer drugs in children with a focus on side effects and age-specific considerations.
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Affiliation(s)
- Georg Hempel
- Westfälische Wilhelms-Universität Münster, Institut für Pharmazeutische und Medizinische Chemie, Klinische Pharmazie, Münster, Germany.
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82
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Liu Y, Li Y, Ni J, Shu Y, Wang H, Hu T. MiR-124 attenuates doxorubicin-induced cardiac injury via inhibiting p66Shc-mediated oxidative stress. Biochem Biophys Res Commun 2020; 521:420-426. [DOI: 10.1016/j.bbrc.2019.10.157] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 10/21/2019] [Indexed: 01/17/2023]
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Bansal N, Adams MJ, Ganatra S, Colan SD, Aggarwal S, Steiner R, Amdani S, Lipshultz ER, Lipshultz SE. Strategies to prevent anthracycline-induced cardiotoxicity in cancer survivors. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2019; 5:18. [PMID: 32154024 PMCID: PMC7048046 DOI: 10.1186/s40959-019-0054-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/16/2019] [Indexed: 12/11/2022]
Abstract
Cancer diagnostics and therapies have improved steadily over the last few decades, markedly increasing life expectancy for patients at all ages. However, conventional and newer anti-neoplastic therapies can cause short- and long-term cardiotoxicity. The clinical implications of this cardiotoxicity become more important with the increasing use of cardiotoxic drugs. The implications are especially serious among patients predisposed to adverse cardiac effects, such as youth, the elderly, those with cardiovascular comorbidities, and those receiving additional chemotherapies or thoracic radiation. However, the optimal strategy for preventing and managing chemotherapy-induced cardiotoxicity remains unknown. The routine use of neurohormonal antagonists for cardioprotection is not currently justified, given the marginal benefits and associated adverse events, particularly with long-term use. The only United States Food and Drug Administration and European Medicines Agency approved treatment for preventing anthracycline-related cardiomyopathy is dexrazoxane. We advocate administering dexrazoxane during cancer treatment to limit the cardiotoxic effects of anthracycline chemotherapy.
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Affiliation(s)
- Neha Bansal
- Division of Pediatric Cardiology, Children’s Hospital at Montefiore, Bronx, NY USA
| | - M. Jacob Adams
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA USA
- Cardio-Oncology Program, Dana-Farber Cancer Institute / Brigham and Women’s Hospital, Boston, MA USA
| | - Steven D. Colan
- Department of Pediatric Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Sanjeev Aggarwal
- Division of Pediatric Cardiology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI USA
| | | | - Shahnawaz Amdani
- Division of Pediatric Cardiology, Cleveland Clinic Children’s Hospital, Cleveland, OH USA
| | - Emma R. Lipshultz
- Dana-Farber Cancer Institute, Boston, MA USA
- University of Miami Miller School of Medicine, Miami, FL USA
| | - Steven E. Lipshultz
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Oishei Children’s Hospital, 1001 Main Street, Buffalo, NY 14203 USA
- Oishei Children’s Hospital, Buffalo, NY USA
- Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
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84
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Zhen J, Yu H, Ji H, Cai L, Leng J, Keller BB. Neonatal murine engineered cardiac tissue toxicology model: Impact of dexrazoxane on doxorubicin induced injury. Life Sci 2019; 239:117070. [PMID: 31751580 DOI: 10.1016/j.lfs.2019.117070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/28/2019] [Accepted: 11/14/2019] [Indexed: 02/06/2023]
Abstract
Doxorubicin (DOX) induced cardiotoxicity is a life-threatening side effect of chemotherapy and decreased cardiac function can present years after treatment. Despite the investigation of a broad range of pharmacologic interventions, to date the only drug shown to reduce DOX-related cardiotoxicity in preclinical studies and limited clinical trials is the iron chelating agent, dexrazoxane (DRZ), although the mechanisms responsible for DRZ mediated protection from DOX related cardiotoxicity remain unclear. Engineered cardiac tissues (ECTs) can be used for tissue repair strategies and as in vitro surrogate models to test cardiac toxicities and preventative countermeasures. Neonatal murine ECTs display cardiotoxicity in response to the environmental toxin, cadmium, and reduced cadmium toxicity with Zinc co-treatment, in part via the induction of the anti-oxidant Metallothionein (MT). We adapted our in vitro ECT model to determine the feasibility of using the ECT approach to investigate DOX-related cardiac injury and DRZ prevention. We found: (1) DOX induced dose and time dependent cell death in ECTs; (2) Zinc did not show protection from DOX cardiotoxicity; (3) MT overexpression induced by Zinc, low dose Cd pretreatment, or MT-overexpression (MT-TG) did not reduce ECT DOX cardiotoxicity; (4) DRZ reduced ECT DOX induced cell death; and (5) The mechanism of DRZ ECT protection from DOX cardiotoxicity was topoisomerase 2B (TOP2B) inhibition rather than reduced reactive oxygen species. Our data support the feasibility of ECTs as an in vitro platform technology for the investigation of drug induced cardiotoxicities including the role of TOP2B in DOX toxicity and DRZ mediated DOX toxicity prevention.
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Affiliation(s)
- Juan Zhen
- The First Hospital of Jilin University, Changchun 130021, China; The Pediatric Research Institute, Department of Pediatrics, the University of Louisville School of Medicine, Louisville, KY 40292, USA
| | - Haitao Yu
- The First Hospital of Jilin University, Changchun 130021, China; The Pediatric Research Institute, Department of Pediatrics, the University of Louisville School of Medicine, Louisville, KY 40292, USA
| | - Honglei Ji
- The First Hospital of Jilin University, Changchun 130021, China
| | - Lu Cai
- The Pediatric Research Institute, Department of Pediatrics, the University of Louisville School of Medicine, Louisville, KY 40292, USA; Department of Radiation Oncology, the University of Louisville School of Medicine, Louisville, KY, USA; Department of Pharmacology and Toxicology, University of Louisville, Louisville, KY 40202, USA
| | - Jiyan Leng
- The First Hospital of Jilin University, Changchun 130021, China.
| | - Bradley B Keller
- Department of Pharmacology and Toxicology, University of Louisville, Louisville, KY 40202, USA; Kosair Charities Pediatric Heart Research Program, Cardiovascular Innovation Institute, University of Louisville School of Medicine, Louisville, KY 40202, USA.
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85
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Kopp LM, Womer RB, Schwartz CL, Ebb DH, Franco VI, Hall D, Barkauskas DA, Krailo MD, Grier HE, Meyers PA, Wexler LH, Marina NM, Janeway KA, Gorlick R, Bernstein ML, Lipshultz SE. Effects of dexrazoxane on doxorubicin-related cardiotoxicity and second malignant neoplasms in children with osteosarcoma: a report from the Children's Oncology Group. CARDIO-ONCOLOGY 2019; 5:15. [PMID: 32154021 PMCID: PMC7048050 DOI: 10.1186/s40959-019-0050-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/10/2019] [Indexed: 11/12/2022]
Abstract
Background Dexrazoxane protects from lower-cumulative-dose doxorubicin cardiotoxicity, but the effect of dexrazoxane in children with sarcoma treated with higher-cumulative-dose doxorubicin is unknown. Methods We evaluated children with osteosarcoma (OS) on two Children's Oncology Group trials with higher dose doxorubicin (375-600 mg/m2) preceded by dexrazoxane (10:1 dexrazoxane:doxorubicin dosing). They were evaluated after the minimum expected treatment time (METT), defined as 28 weeks. Cardiotoxicity was identified by echocardiography and serum N-terminal pro-brain natriuretic peptide (NT-proBNP). Second malignant neoplasm (SMN) data was collected. Results All children had normal left ventricular (LV) systolic function as measured by LV fractional shortening and no heart failure. The end-diastolic septal thickness Z-scores (P < 0.01) and LV mass Z-scores (P < 0.01) were significantly smaller than normal for body-surface area in both sexes. The average LV mass Z-scores were significantly smaller for girls (P < 0.01) and marginally smaller for boys (P = 0.06). Girls had significantly smaller LV end-diastolic dimension Z-scores normalized to BSA (P < 0.01) compared to healthy controls and had significant increases in NT-proBNP. Four children developed SMNs as first events, a rate similar to historical controls. Conclusions Dexrazoxane prevented LV dysfunction and heart failure in children with OS receiving higher dose doxorubicin. However, LV structural changes were not fully prevented, especially in girls. As a result, hearts become abnormally small for body size, resulting in higher LV stress. Dexrazoxane did not increase the risk of SMN. Dexrazoxane should be used in this population, particularly for girls, to mitigate anthracycline-induced cardiotoxicity. Trial registrations ClinicalTrials.gov: NCT00003937 (P9754) registered 1 Nov 1999, and NCT00023998 (AOST0121) registered 13 Sept 2001.
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Affiliation(s)
- Lisa M Kopp
- 1Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, 1295 N Martin Ave. PO Box 245210, Tucson, AZ 85724 USA.,2University of Arizona Cancer Center, University of Arizona, Tucson, AZ USA
| | | | - Cindy L Schwartz
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI USA
| | - David H Ebb
- 5Department of Pediatric Hematology-Oncology, Massachusetts General Hospital, Boston, MA USA
| | - Vivian I Franco
- 6Department of Pediatrics, University at Buffalo, Oishei Children's Hospital, Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
| | - David Hall
- 7Children's Oncology Group, Monrovia, CA USA
| | - Donald A Barkauskas
- 7Children's Oncology Group, Monrovia, CA USA.,8Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | - Mark D Krailo
- 7Children's Oncology Group, Monrovia, CA USA.,8Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | | | - Paul A Meyers
- 10Memorial Sloan Kettering Cancer Center, New York, NY USA
| | | | - Neyssa M Marina
- 11Five Prime Therapeutics, Inc., South San Francisco, CA USA
| | | | | | | | - Steven E Lipshultz
- 6Department of Pediatrics, University at Buffalo, Oishei Children's Hospital, Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
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86
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Abbas AA, AlAzmi AAM. Anthracycline‑Induced Cardiac Toxicity: A Clinical Review. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_106_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractAnthracyclines (ATCs) have a great efficacy against many types of cancer and is currently considered a cornerstone in the treatment of numerous pediatric and adult hematological and solid tumors. Great advances have been achieved after the entry of ATC group into the cancer treatment in the early 1960s, and the overall survival ratio has increased from 30% to near 70%. Due to their significant role and great value in cancer therapy, which is persistent to date, ATCs are listed in the World Health Organization model list of essential medicines. The clinical use of ATC such as doxorubicin and daunorubicin can be viewed as a sort of double-edged sword. On the one hand, ATCs play an undisputed key role in the treatment of many neoplastic diseases; on the other hand, the administration of ATC is associated with the risk of severe adverse effects. The most common side effect of the ATC group is cardiotoxicity (CTX), which may limit its use and increases mortality and morbidity rates. The clinical use of ATC is limited by unique maximum total cumulative dose (approximately 350 mg/m2) limiting CTX. ATC CTX is cumulative dose-dependent and is in most of the occasions irreversible. Lowering the cumulative dose has been proved to be useful in minimize the risk of heart failure (HF), but, yet, there is a growing concern that HF might occur following doses that were thought to be safe. The average incidence of HF is around 5% at a cumulative dose of 400 mg/m2 that becomes higher above 500 mg/m2, albeit with substantial individual variation. The newer generations ATC medications such as epirubicin, idarubicin, and mitoxantrone were thought to be safer; however, subsequent clinical studies showed more or less similar toxicity profiles. The use of cardioprotective agents (e.g., dexrazoxane and amifostine) has been associated with improved safety range; however, questions are looming on their effect on ATC antitumor effects. An overwhelming amount of clinical evidence suggests that ATCs are too good to be old. Yet, they would look much better if they caused less harm to the heart when administered as either single agents or in combination with otherwise promising new drugs. In this review article, we present a comprehensive account on the ATC and provide up to date data on their clinical use and toxicity profile. In addition, we provide a contemporary approach on the early detection, diagnosis, and treatment of ATC CTX.
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Affiliation(s)
- Adil Abdelhameed Abbas
- Department of Pediatrics, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh
- Princess Nourah Oncology Centre, King Abdulaziz Medical City
| | - Aeshah Abdu Mubarak AlAzmi
- Princess Nourah Oncology Centre, King Abdulaziz Medical City
- Department of Pharmacology, College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
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87
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The Evolving Design of NIH-Funded Cardio-Oncology Studies to Address Cancer Treatment-Related Cardiovascular Toxicity. JACC: CARDIOONCOLOGY 2019; 1:105-113. [PMID: 32529192 PMCID: PMC7288847 DOI: 10.1016/j.jaccao.2019.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardiovascular (CV) toxicity from cancer therapy is a significant and growing concern. Conventional oncology clinical trial designs focused solely on cancer treatment efficacy have not provided sufficient information on both CV risk factors and outcomes. Similarly, traditional CV trials evaluating standard interventions typically exclude cancer patients, particularly those actively receiving cancer therapy. Neither trial type simultaneously evaluates the balance between CV toxicity and cancer outcomes; however, there is increasing collaboration among oncologists and cardiologists to design new cardio-oncology trials that address this important need. In this review, we detail 5 ongoing, oncology-based trials with integrated CV endpoints. Key design features include: 1) a careful assessment of CV risk factors and disease before, during, and after cancer therapy with standardized collection of clinical imaging, functional, and biomarker data; 2) an introduction of cardioprotective interventions at various timepoints in cancer therapy; 3) a balance of the risk of subclinical CV injury with the need for ongoing cancer treatment; and 4) an understanding of the time profile for development of clinically apparent CV toxicity. Additional critical priorities in cardio-oncology clinical research include harmonization of data collection and definitions for all physician- and patient-reported exposures and outcomes. Prospective assessment of CV risk factors before, during, and after cancer treatment. Longitudinal monitoring of CV function with standardized review of CV imaging and functional and biomarker endpoints for evidence of subclinical cardiotoxicity. Consideration for the timing of the introduction of the cardioprotective strategy. Need to balance the delivery of cancer treatment with the risk of CV injury. Long-term follow-up beyond cancer treatment intervention to determine clinical cardiotoxicity outcomes. Rigorous collection of cancer and CV endpoints to answer questions about the impact of CV events on the delivery of cancer treatment and the long-term patient outcomes.
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88
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Filomena D, Versacci P, Cimino S, Mattiucci C, Maestrini V, Cantisani D, Petronilli V, Agati L, Schiavetti A. Echocardiographic long-term follow-up of adult survivors of pediatric cancer treated with Dexrazoxane-Anthracyclines association. Int J Cardiol 2019; 299:271-275. [PMID: 31422879 DOI: 10.1016/j.ijcard.2019.07.096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/28/2019] [Accepted: 07/30/2019] [Indexed: 12/22/2022]
Abstract
AIMS Cardiovascular disease is a well-recognized cause of increased late morbidity and mortality among survivors of childhood cancer treated with anthracyclines. Co-administration of Dexrazoxane has been shown to significantly reduce short-term and mid-term cardiotoxicity. Aim of this study was to assess cardiac function in long-term (>10 years) survivors of childhood tumors treated with dexrazoxane/anthracycline association. METHODS AND RESULTS Twenty cancer survivors previously treated with co-administration of anthracyclines-dexrazoxane for childhood renal tumors or sarcoma and a control group of 20 healthy subjects were enrolled in the study. Echocardiographic measurements included 3D left ventricular (LV) ejection fraction (LVEF) and LV and right ventricular (RV) global longitudinal strain (GLS). Among cancer survivors group the median age at diagnosis was 5 years (1-17) and they were evaluated at median follow-up time of 21.5 years (10-26). No evidence of cardiac toxicity, as defined by current guidelines, was reported in all survivors. No significant differences in standard and deformation imaging parameters were observed between survivors and controls (3D LVEF 58 ± 3% vs 60 ± 5% p = NS; LV GLS -21 ± 1% vs -21 ± 2% p = NS; RV GLS -23 ± 2% vs -23 ± 5% p = NS). No second tumor was registered in dexrazoxane-treated survivors. CONCLUSIONS Our findings may support the role of dexrazoxane as a useful strategy for cardio-protection in children undergoing anthracycline based treatment. However, large randomized trials are needed to confirm the cardio-protective role of dexrazoxane in pediatric setting at long-term follow-up.
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Affiliation(s)
- D Filomena
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy.
| | - P Versacci
- Department of Pediatrics, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - S Cimino
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - C Mattiucci
- Department of Pediatrics, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - V Maestrini
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - D Cantisani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - V Petronilli
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - L Agati
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - A Schiavetti
- Department of Pediatrics, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
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89
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Wang W, Tse-Dinh YC. Recent Advances in Use of Topoisomerase Inhibitors in Combination Cancer Therapy. Curr Top Med Chem 2019; 19:730-740. [PMID: 30931861 DOI: 10.2174/1568026619666190401113350] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/31/2019] [Accepted: 02/28/2019] [Indexed: 01/01/2023]
Abstract
Inhibitors targeting human topoisomerase I and topoisomerase II alpha have provided a useful chemotherapy option for the treatment of many patients suffering from a variety of cancers. While the treatment can be effective in many patient cases, use of these human topoisomerase inhibitors is limited by side-effects that can be severe. A strategy of employing the topoisomerase inhibitors in combination with other treatments can potentially sensitize the cancer to increase the therapeutic efficacy and reduce resistance or adverse side effects. The combination strategies reviewed here include inhibitors of DNA repair, epigenetic modifications, signaling modulators and immunotherapy. The ongoing investigations on cellular response to topoisomerase inhibitors and newly initiated clinical trials may lead to adoption of novel cancer therapy regimens that can effectively stop the proliferation of cancer cells while limiting the development of resistance.
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Affiliation(s)
- Wenjie Wang
- Department of Chemistry and Biochemistry, Florida International University, Miami, FL, United States.,Biomolecular Sciences Institute, Florida International University, Miami, FL, United States
| | - Yuk-Ching Tse-Dinh
- Department of Chemistry and Biochemistry, Florida International University, Miami, FL, United States.,Biomolecular Sciences Institute, Florida International University, Miami, FL, United States
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90
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Narayan HK, Putt ME, Kosaraju N, Paz A, Bhatt S, Plappert T, Mercer-Rosa L, Armenian SH, Desai AV, Womer RB, Ky B. Dexrazoxane preferentially mitigates doxorubicin cardiotoxicity in female children with sarcoma. Open Heart 2019; 6:e001025. [PMID: 31297226 PMCID: PMC6593195 DOI: 10.1136/openhrt-2019-001025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/27/2019] [Accepted: 04/26/2019] [Indexed: 01/15/2023] Open
Abstract
Objective We sought to determine how sex and dexrazoxane therapy influence cardiac remodelling in children with sarcoma receiving high-dose doxorubicin. Methods In a retrospective cohort of 85 children with sarcoma receiving high-dose doxorubicin, echocardiography measures prior to, early after (within 6 months of doxorubicin completion) and 1 – 2 years after doxorubicin completion were quantified. At each follow-up visit, multivariable, propensity-adjusted linear regression models evaluated dexrazoxane’s effects on changes in left ventricular (LV) shortening fraction (SF), structure, strain and wall stress for subgroups divided by sex. Likelihood ratio tests assessed the interaction between sex and dexrazoxane in determining these changes. Results Early after doxorubicin completion, males not treated with dexrazoxane (n = 15) developed increased cavity size and diminished circumferential strain; females (n = 8) developed diminished SF and strain indices, and increased cavity size and wall stress. With dexrazoxane, males (n = 33) demonstrated less deterioration in circumferential strain by 3.4% (95% CI 0.01 to 6.8), and females (n = 29) demonstrated less reduction in SF by 5.7% (95% CI 2.1 to 9.3), and had mitigation of increases in cavity size and wall stress. In interaction analyses, females had greater protection with dexrazoxane with regard to SF (p = 0.019) and cavity size in diastole (p = 0.002) and systole (p ≤ 0.001). These findings largely persisted 1 – 2 years after doxorubicin therapy. Conclusions Early, sustained alterations in LV structure and function occur in children with sarcoma after high-dose doxorubicin, with adverse changes and protective effects of dexrazoxane more pronounced in females as compared with males. Dexrazoxane may have sex-specific cardioprotective effects.
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Affiliation(s)
- Hari K Narayan
- Department of Pediatrics, University of California San Diego School of Medicine, San Diego, California, USA.,Rady Children's Hospital San Diego, San Diego, California, USA
| | - Mary E Putt
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nikitha Kosaraju
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alejandro Paz
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shivani Bhatt
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theodore Plappert
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura Mercer-Rosa
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Saro H Armenian
- Department of Population Sciences, City of Hope National Medical Center, Duarte, California, USA
| | - Ami V Desai
- Department of Pediatrics, University of Chicago, Chicago, Illinois, USA
| | - Richard B Womer
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Abramson Cancer Center, Philadelphia, Pennsylvania, USA
| | - Bonnie Ky
- Department of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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91
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Lipshultz SE, Law YM, Asante-Korang A, Austin ED, Dipchand AI, Everitt MD, Hsu DT, Lin KY, Price JF, Wilkinson JD, Colan SD. Cardiomyopathy in Children: Classification and Diagnosis: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e9-e68. [PMID: 31132865 DOI: 10.1161/cir.0000000000000682] [Citation(s) in RCA: 165] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this scientific statement from the American Heart Association, experts in the field of cardiomyopathy (heart muscle disease) in children address 2 issues: the most current understanding of the causes of cardiomyopathy in children and the optimal approaches to diagnosis cardiomyopathy in children. Cardiomyopathies result in some of the worst pediatric cardiology outcomes; nearly 40% of children who present with symptomatic cardiomyopathy undergo a heart transplantation or die within the first 2 years after diagnosis. The percentage of children with cardiomyopathy who underwent a heart transplantation has not declined over the past 10 years, and cardiomyopathy remains the leading cause of transplantation for children >1 year of age. Studies from the National Heart, Lung, and Blood Institute-funded Pediatric Cardiomyopathy Registry have shown that causes are established in very few children with cardiomyopathy, yet genetic causes are likely to be present in most. The incidence of pediatric cardiomyopathy is ≈1 per 100 000 children. This is comparable to the incidence of such childhood cancers as lymphoma, Wilms tumor, and neuroblastoma. However, the published research and scientific conferences focused on pediatric cardiomyopathy are sparcer than for those cancers. The aim of the statement is to focus on the diagnosis and classification of cardiomyopathy. We anticipate that this report will help shape the future research priorities in this set of diseases to achieve earlier diagnosis, improved clinical outcomes, and better quality of life for these children and their families.
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Pediatric Cardio-Oncology: Development of Cancer Treatment-Related Cardiotoxicity and the Therapeutic Approach to Affected Patients. Curr Treat Options Oncol 2019; 20:56. [PMID: 31129800 DOI: 10.1007/s11864-019-0658-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OPINION STATEMENT The past 5 decades have seen significant improvements in outcomes for pediatric patients with cancer. Unfortunately, children and adolescents who have been treated for cancer are five to six times more likely to develop cardiovascular disease as a result of their therapies. Cardiovascular disease may manifest in a plethora of ways, from asymptomatic ventricular dysfunction to end-stage heart failure, hypertension, arrhythmia, valvular disease, early coronary artery disease, or peripheral vascular disease. A number of treatment modalities are implicated in pediatric and adult populations, including anthracyclines, radiation therapy, alkylating agents, targeted cancer therapies (small molecules and antibody therapies), antimetabolites, antimicrotubule agents, immunotherapy, interleukins, and chimeric antigen receptor T cells. For some therapies, such as anthracyclines, the mechanism of injury is elucidated, but for many others it is not. While a few protective strategies exist, in many cases, observation and close monitoring is the only defense against developing end-stage cardiovascular disease. Because of the variety of potential outcomes after cancer therapy, a one-size-fits-all approach is not appropriate. Rather, a good working relationship between oncology and cardiology to assess the risks and benefits of various therapies and planning for appropriate surveillance is the best model. When disease is identified, any of a number of therapies may be appropriate; however, in the pediatric and adolescent population supportive data are limited.
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93
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Chow EJ, Leger KJ, Bhatt NS, Mulrooney DA, Ross CJ, Aggarwal S, Bansal N, Ehrhardt MJ, Armenian SH, Scott JM, Hong B. Paediatric cardio-oncology: epidemiology, screening, prevention, and treatment. Cardiovasc Res 2019; 115:922-934. [PMID: 30768157 PMCID: PMC6452306 DOI: 10.1093/cvr/cvz031] [Citation(s) in RCA: 70] [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: 11/10/2018] [Revised: 01/18/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022] Open
Abstract
With 5-year survival of children with cancer exceeding 80% in developed countries, premature cardiovascular disease is now a major cause of early morbidity and mortality. In addition to the acute and chronic cardiotoxic effects of anthracyclines, related chemotherapeutics, and radiation, a growing number of new molecular targeted agents may also have detrimental effects on the cardiovascular system. Survivors of childhood cancer also may have earlier development of conventional cardiovascular risk factors such as hypertension, dyslipidaemia, and diabetes, which further increase their risk of serious cardiovascular disease. This review will examine the epidemiology of acute and chronic cardiotoxicity relevant to paediatric cancer patients, including genetic risk factors. We will also provide an overview of current screening recommendations, including the evidence regarding both imaging (e.g. echocardiography and magnetic resonance imaging) and blood-based biomarkers. Various primary and secondary prevention strategies will also be discussed, primarily in relation to anthracycline-related cardiomyopathy. Finally, we review the available evidence related to the management of systolic and diastolic dysfunction in paediatric cancer patients and childhood cancer survivors.
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Affiliation(s)
- Eric J Chow
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N., PO Box 19024, Mailstop M4-C308, Seattle, WA 98109, USA
| | - Kasey J Leger
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Neel S Bhatt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Daniel A Mulrooney
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Colin J Ross
- Faculty of Pharmaceutical Sciences, University of British Columbia, BC Children’s Hospital, Vancouver, BC, Canada
| | - Sanjeev Aggarwal
- Division of Pediatric Cardiology, Children’s Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Neha Bansal
- Division of Pediatric Cardiology, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew J Ehrhardt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Saro H Armenian
- Department of Population Sciences, City of Hope Medical Center, Duarte, CA, USA
| | - Jessica M Scott
- Exercise Oncology Research Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Borah Hong
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
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94
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Anand K, Pingali SR, Trachtenberg B, Iyer SP. Complete Response to R-EPOCH in Primary Cardiac Lymphoma. Case Rep Hematol 2019; 2019:7690430. [PMID: 31214365 PMCID: PMC6535821 DOI: 10.1155/2019/7690430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/21/2019] [Indexed: 11/17/2022] Open
Abstract
Primary cardiac lymphoma (PCL) is a rare extranodal lymphoma involving only the heart and/or the pericardium. Most common presenting signs and symptoms are nonspecific including dyspnea, pericardial effusion, and arrhythmia. Prognosis of PCL patients remain poor compared to non-cardiac lymphoma patients. Since most of the information about PCL comes from case reports or case series, there is no treatment consensus. Anthracycline containing chemotherapy remains main treatment modality which is potentially cardiotoxic. We present a case of PCL that achieved complete remission using R-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin). We also used dexrazoxane in an effort to reduce cardiotoxicity of chemotherapy.
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Affiliation(s)
- Kartik Anand
- Houston Methodist Cancer Center, Weill Cornell Medicine, Houston, TX, USA
| | - Sai Ravi Pingali
- Houston Methodist Cancer Center, Weill Cornell Medicine, Houston, TX, USA
| | - Barry Trachtenberg
- Division of Cardiology, DeBakey Heart & Vascular Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Swaminathan Padmanabhan Iyer
- Houston Methodist Cancer Center, Weill Cornell Medicine, Houston, TX, USA
- Department of Lymphoma/Myeloma, UT MD Anderson Cancer Center, Houston, TX, USA
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95
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Cardinale D, Stivala F, Cipolla CM. Oncologic therapies associated with cardiac toxicities: how to minimize the risks. Expert Rev Anticancer Ther 2019; 19:359-374. [DOI: 10.1080/14737140.2019.1596804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Daniela Cardinale
- Cardioncology Unit, Cardiology Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
| | - Federica Stivala
- Cardioncology Unit, Cardiology Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
| | - Carlo M. Cipolla
- Cardioncology Unit, Cardiology Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
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96
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Abstract
PURPOSE OF REVIEW The anthracycline (AC) group of drugs is widely used for cancer chemotherapy and has improved outcomes in many childhood malignancies. However, cardiovascular complications are major causes of morbidity and mortality in AC recipients, with the greatest risk factor being a higher cumulative dosage. The purpose of this review is to describe the etio-pathogenesis and risk factors of AC induced cardiotoxicity, with emphasis on currently available and emerging modalities of non-invasive imaging in its surveillance, and to review guidelines on its prevention and treatment. RECENT FINDINGS Presently, ejection fraction and shortening fraction derived from two-dimensional echocardiography are the most widely used parameter for monitoring of cardiac function in childhood cancer survivors. The newer speckle tracking echocardiography has shown potential to detect abnormalities in ventricular function prior to the conventional measures such as ejection fraction and shortening fraction. When available, three-dimensional echocardiography should be used as it allows for more accurate estimation of ejection fraction. Newer magnetic resonance imaging (MRI) techniques, such as delayed enhancement and T1 mapping, are useful adjuncts for cardiac evaluation in cancer survivors, especially in patients with poor echocardiographic windows. Early detection and management of cardiovascular diseases is one of the major goals in the long-term follow-up of childhood cancer survivors. In addition to conventional two-dimensional echocardiography, newer techniques such as speckle tracking echocardiography and three-dimensional echocardiography should be incorporated due to its ability to detect early changes in anthracycline-induced cardiotoxicity. However further research are needed to guide changes in management due to abnormalities in speckle tracking echocardiography.
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97
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Gong F, Meng Q, Liu C, Zhao Y. Efficacy and association analysis of high-dose methotrexate in the treatment of children with acute lymphoblastic leukemia. Oncol Lett 2019; 17:4423-4428. [PMID: 30988812 PMCID: PMC6447950 DOI: 10.3892/ol.2019.10128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/15/2019] [Indexed: 01/24/2023] Open
Abstract
Effect of high-dose methotrexate (MTX) on children with acute lymphoblastic leukemia (ALL) with different subtypes and disease courses was investigated. A retrospective analysis of 207 children with ALL who were admitted to the People's Hospital of Pingyi County from March 2014 to June 2017 was carried out. According to the subtype of the disease, the children were divided into two groups. B-lineage group: ALL occurred in B-lineage lymphocytes (n=128); T-lineage group: ALL occurred in T-lineage lymphocytes (n=79). According to the disease course, the children were divided into three groups. High-risk group: disease course >15 days (n=67); moderate-risk group: disease course >8 and <15 days (n=58); low-risk group: disease course <8 days (n=82). The plasma concentration, calcium formyltetrahydrofolate (CF) rescue times and adverse reactions were compared at 12 h (T1), 48 h (T2), and 72 h (T3) after MTX infusion. The plasma concentration in B-lineage group was significantly higher than that in the T-lineage group at T2 and T3 (P<0.05). The incidence of adverse reactions in children with ALL in the B-lineage group was significantly higher than that in the T-lineage group (P<0.05). The CF rescue times in high-risk group were more than that in moderate- and low-risk groups (P<0.05). The incidence of adverse reactions in the high-risk group was significantly higher than that in the moderate- and low-risk groups (P<0.05), and in the moderate-risk group was significantly higher than that in the low-risk group (P<0.05). Compared with T-lineage ALL children, high-dose MTX causes more toxic injury to B-lineage ALL children. During clinical application of MTX in the treatment of ALL, close attention should be paid to the changes of the vital signs of patients, and timely CF rescue should be performed.
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Affiliation(s)
- Fangwei Gong
- Ward 2, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
| | - Qingjun Meng
- Ward 2, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
| | - Chengjuan Liu
- Ward 2, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
| | - Yeqi Zhao
- Ward 6, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
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98
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Tuzovic M, Mead M, Young PA, Schiller G, Yang EH. Cardiac Complications in the Adult Bone Marrow Transplant Patient. Curr Oncol Rep 2019; 21:28. [PMID: 30826891 DOI: 10.1007/s11912-019-0774-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Due to advancements in oncologic treatment strategies and techniques, the number of survivors who have undergone hematopoetic stem cell transplant (HCT) continues to increase in the United States; this number is projected to reach 502,000 by the year 2030. There is significant interest within the field of cardio-oncology to identify cardiotoxicity and cardiovascular disease in the HCT population. Epidemiologic studies analyzing both short- and long-term cardiovascular effects, risk stratification modeling, cardioprotective strategies, and expert consensus documents for cardiotoxicity surveillance recommendations are reviewed. RECENT FINDINGS Patients who have undergone HCT are at increased risk of cardiovascular events and mortality compared to matched controls. The type of cardiotoxicity and the incidence rates vary based on specific therapeutic regimens and pre-existing cardiovascular risk factors. Life-threatening cardiotoxicity can present during HCT as acute heart failure, arrhythmias, pericardial tamponade, or cardiac arrest; or it can present late after treatment as cardiomyopathy, ischemic heart disease, vascular disease, stroke, or comorbid conditions, such as hypertension and diabetes mellitus that are associated with cardiac events. HCT is associated with excess cardiovascular risk partially due to exposure to cardiotoxic chemotherapy and radiation, as well as indirect and direct detrimental effects on cardiovascular reserve. This review discusses the epidemiology and the known cardiotoxic effects of historical chemoradiation agents in addition to newer targeted therapies. Recent expert consensus statements from cardiology and hematology/oncology societies are reviewed in regard to risk stratification of the cancer patient based on the type of treatments. Finally, gaps in knowledge are identified with proposed avenues of research that will allow for more accurate risk assessment, prediction, and potential treatment of the HCT patient in attenuating the risk of developing both short- and long-term cardiovascular comorbidities.
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Affiliation(s)
- Mirela Tuzovic
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Monica Mead
- Division of Hematology and Oncology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Patricia A Young
- Division of Hematology and Oncology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Gary Schiller
- Division of Hematology and Oncology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
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99
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Wang H, Lou C, Ma N. Forskolin exerts anticancer roles in non-Hodgkin's lymphomas via regulating Axin/β-catenin signaling pathway. Cancer Manag Res 2019; 11:1685-1696. [PMID: 30863177 PMCID: PMC6388987 DOI: 10.2147/cmar.s180754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Non-Hodgkin’s lymphomas (NHLs) account for 85% of lymphomas, which are characterized by high-degree malignancy, rapid progress, and even invasion into central nervous system in pediatric patients. Although the cure rate of pediatric NHL has improved, some patients have still underwent recurrence or death. This study focuses on the effects and mechanism of forskolin on the progression of NHL, aiming to find efficient therapy methods for pediatric NHL. Methods MTT, flow cytometry and mice tumor bearing experiments were used to evaluate the effects of forskolin on NHL cell proliferation, apoptosis and tumorigenesis. Western blotting and RT-PCR assays were used to detect protein and mRNA expression. Immunohistochemistry technology was recruited to analyze Ki-67 expression in tumor tissues. Results Forskolin significantly increased the expression of cleaved caspase-3/9 in both NHL Toledo and NK-92 cell lines, and inhibited cell growth. Besides, forskolin obviously reduced the expression of β-catenin protein, promoted its ubiquitination, enhanced its transportation from nuclear to cytoplasm, as well as decreased the expression of its downstream oncogenes c-myc and cyclin D1 through upregulating Axin expression and stability and inhibiting Axin ubiquitination. Moreover, forskolin enhanced the effects of SP600125, an inhibitor of c-Jun N-terminal kinase signaling on cell apoptosis promotion and tumorigenesis inhibition via Axin-induced β-catenin signaling repression. Conclusion The current study clarifies that forskolin can inhibit the progression of NHL through Axin-mediated inhibition of β-catenin signaling. Moreover, forskolin improves the effects of SP600125 on cell apoptosis enhancement and tumorigenesis inhibition of NHL cells. These findings provide theoretical foundation of serving forskolin as a new effective therapeutic drug for pediatric NHL.
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Affiliation(s)
- Hailei Wang
- Department of Pediatrics, Huaihe Hospital of Henan University, Kaifeng, Henan, China
| | - Chunyan Lou
- Department of Pediatrics, Huaihe Hospital of Henan University, Kaifeng, Henan, China
| | - Na Ma
- Department of Neurology, Henan Kaifeng Children's Hospital, Kaifeng, Henan, China,
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100
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Changing Hearts and Minds: Improving Outcomes in Cancer Treatment-Related Cardiotoxicity. Curr Oncol Rep 2019; 21:9. [DOI: 10.1007/s11912-019-0751-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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