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Liu X, Ge S, Zhang A. Pediatric Cardio-Oncology: Screening, Risk Stratification, and Prevention of Cardiotoxicity Associated with Anthracyclines. CHILDREN (BASEL, SWITZERLAND) 2024; 11:884. [PMID: 39062333 PMCID: PMC11276082 DOI: 10.3390/children11070884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/02/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024]
Abstract
Anthracyclines have significantly improved the survival of children with malignant tumors, but the associated cardiotoxicity, an effect now under the purview of pediatric cardio-oncology, due to its cumulative and irreversible effects on the heart, limits their clinical application. A systematic screening and risk stratification approach provides the opportunity for early identification and intervention to mitigate, reverse, or prevent myocardial injury, remodeling, and dysfunction associated with anthracyclines. This review summarizes the risk factors, surveillance indexes, and preventive strategies of anthracycline-related cardiotoxicity to improve the safety and efficacy of anthracyclines.
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Affiliation(s)
- Xiaomeng Liu
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Shuping Ge
- Department of Pediatric and Adult Congenital Cardiology, Geisinger Clinic, Danville, PA 17822, USA
| | - Aijun Zhang
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan 250012, China
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2
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Ehrhardt MJ, Liu Q, Mulrooney DA, Rhea IB, Dixon SB, Lucas JT, Sapkota Y, Shelton K, Ness KK, Srivastava DK, McDonald A, Robison LL, Hudson MM, Yasui Y, Armstrong GT. Improved Cardiomyopathy Risk Prediction Using Global Longitudinal Strain and N-Terminal-Pro-B-Type Natriuretic Peptide in Survivors of Childhood Cancer Exposed to Cardiotoxic Therapy. J Clin Oncol 2024; 42:1265-1277. [PMID: 38207238 PMCID: PMC11095874 DOI: 10.1200/jco.23.01796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/27/2023] [Accepted: 10/26/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE To leverage baseline global longitudinal strain (GLS) and N-terminal-pro-B-type natriuretic peptide (NT-proBNP) to identify childhood cancer survivors with a normal left ventricular ejection fraction (LVEF) at highest risk of future treatment-related cardiomyopathy. METHODS St Jude Lifetime Cohort participants ≥5 years from diagnosis, at increased risk for cardiomyopathy per the International Guideline Harmonization Group (IGHG), with an LVEF ≥50% on baseline echocardiography (n = 1,483) underwent measurement of GLS (n = 1,483) and NT-proBNP (n = 1,052; 71%). Multivariable Cox regression models estimated hazard ratios (HRs) and 95% CIs for postbaseline cardiomyopathy (modified Common Terminology Criteria for Adverse Events ≥grade 2) incidence in association with echocardiogram-based GLS (≥-18) and/or NT-proBNP (>age-sex-specific 97.5th percentiles). Prediction performance was assessed using AUC in models with and without GLS and NT-proBNP and compared using DeLong's test for IGHG moderate- and high-risk individuals treated with anthracyclines. RESULTS Among survivors (median age, 37.6; range, 10.2-70.4 years), 162 (11.1%) developed ≥grade 2 cardiomyopathy 5.1 (0.7-10.0) years from baseline assessment. The 5-year cumulative incidence of cardiomyopathy for survivors with and without abnormal GLS was, respectively, 7.3% (95% CI, 4.7 to 9.9) versus 4.4% (95% CI, 3.0 to 5.7) and abnormal NT-proBNP was 9.9% (95% CI, 5.8 to 14.1) versus 4.7% (95% CI, 3.2 to 6.2). Among survivors with a normal LVEF, abnormal baseline GLS and NT-proBNP identified anthracycline-exposed, IGHG-defined moderate-/high-risk survivors at a four-fold increased hazard of postbaseline cardiomyopathy (HR, 4.39 [95% CI, 2.46 to 7.83]; P < .001), increasing to a HR of 14.16 (95% CI, 6.45 to 31.08; P < .001) among survivors who received ≥250 mg/m2 of anthracyclines. Six years after baseline, AUCs for individual risk prediction were 0.70 for models with and 0.63 for models without GLS and NT-proBNP (P = .022). CONCLUSION GLS and NT-proBNP should be considered for improved identification of survivors at high risk for future cardiomyopathy.
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Affiliation(s)
- Matthew J. Ehrhardt
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Daniel A. Mulrooney
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Isaac B. Rhea
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Stephanie B. Dixon
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - John T. Lucas
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Yadav Sapkota
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Kyla Shelton
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | | | - Aaron McDonald
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Melissa M. Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
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Leerink JM, Feijen EA, de Baat EC, Merkx R, van der Pal HJ, Tissing WJ, Louwerens M, van den Heuvel-Eibrink MM, Versluys AB, van Dalen EC, van der Heiden-van der Loo M, Bresters D, Ronckers CM, de Vries AC, Neggers S, Kapusta L, Loonen J, Pinto YM, Kremer LC, Mavinkurve-Groothuis AM, Kok WE. A Biomarker-Based Diagnostic Model for Cardiac Dysfunction in Childhood Cancer Survivors. JACC CardioOncol 2024; 6:236-247. [PMID: 38774012 PMCID: PMC11103045 DOI: 10.1016/j.jaccao.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 05/24/2024] Open
Abstract
Background Childhood cancer survivors at risk for heart failure undergo lifelong echocardiographic surveillance. Previous studies reported the limited diagnostic accuracy of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) in detecting left ventricular (LV) dysfunction. However, potential enhanced diagnostic accuracy through the combination of biomarkers and clinical characteristics has been suggested. Objectives The aim of this study was to develop and internally validate a diagnostic model that combines cardiac biomarkers with clinical characteristics for effectively ruling in or ruling out LV dysfunction in childhood cancer survivors. Methods A multicenter cross-sectional study included 1,334 survivors (median age 34.2 years) and 278 siblings (median age 36.8 years). Logistic regression models were developed and validated through bootstrapping, combining biomarkers with clinical characteristics. Results Abnormal NT-proBNP levels were observed in 22.1% of survivors compared with 5.4% of siblings, whereas hs-cTnT levels exceeding 10 ng/L were uncommon in both survivors (5.9%) and siblings (5.0%). The diagnostic models demonstrated improvement upon the addition of NT-proBNP and hs-cTnT to clinical characteristics, resulting in an increased C statistic from 0.69 to 0.73 for LV ejection fraction (LVEF) <50% and a more accurate prediction of more severe LV dysfunction, with the C statistic increasing from 0.80 to 0.86 for LVEF <45%. For LVEF <50% (prevalence 10.9%), 16.9% of survivors could be effectively ruled out with high sensitivity (95.4%; 95% CI: 90.4%-99.3%) and negative predictive value (97.5%; 95% CI: 94.6%-99.7%). Similarly, for LVEF <45% (prevalence 3.4%), 53.0% of survivors could be ruled out with moderate to high sensitivity (91.1%; 95% CI: 79.2%-100%) and high negative predictive value (99.4%; 95% CI: 98.7%-100%). Conclusions The biomarker-based diagnostic model proves effective in ruling out LV dysfunction, offering the potential to minimize unnecessary surveillance echocardiography in childhood cancer survivors. External validation is essential to confirm these findings. (Early Detection of Cardiac Dysfunction in Childhood Cancer Survivors; A DCOG LATER Study; https://onderzoekmetmensen.nl/nl/trial/23641).
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Affiliation(s)
- Jan M. Leerink
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Esmee C. de Baat
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Remy Merkx
- Radboud University Medical Center, Department of Medical Imaging, Nijmegen, the Netherlands
| | | | - Wim J.E. Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Beatrix Children’s Hospital, Department of Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marloes Louwerens
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Marry M. van den Heuvel-Eibrink
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
- University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | | | | | | | - Dorine Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Willem Alexander Children’s Hospital/Leiden University Medical Center, Leiden, the Netherlands
| | - Cécile M. Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Andrica C.H. de Vries
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sebastian Neggers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Medicine, Section Endocrinology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Livia Kapusta
- Radboud University Medical Center, Department of Pediatric Cardiology, Amalia Children’s Hospital, Nijmegen, the Netherlands
- Pediatrics, Pediatric Cardiology Unit, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacqueline Loonen
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Yigal M. Pinto
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Leontien C.M. Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht, the Netherlands
- Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Amsterdam, the Netherlands
| | | | - Wouter E.M. Kok
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Noyd DH, Bailey A, Janitz A, Razzaghi T, Bouvette S, Beasley W, Baker A, Chen S, Bard D. Rurality, Cardiovascular Risk Factors, and Early Cardiovascular Disease among Childhood, Adolescent, and Young Adult Cancer Survivors. RESEARCH SQUARE 2024:rs.3.rs-4139837. [PMID: 38645102 PMCID: PMC11030544 DOI: 10.21203/rs.3.rs-4139837/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background and Aims Cardiovascular risk factors (CVRFs) later in life potentiate risk for late cardiovascular disease (CVD) from cardiotoxic treatment among survivors. This study evaluated the association of baseline CVRFs and CVD in the early survivorship period. Methods This analysis included patients ages 0-29 at initial diagnosis and reported in the institutional cancer registry between 2010 and 2017 (n = 1228). Patients who died within five years (n = 168), those not seen in the oncology clinic (n = 312), and those with CVD within one year of diagnosis (n = 17) were excluded. CVRFs (hypertension, diabetes, dyslipidemia, and obesity) within one year of initial diagnosis, were constructed and extracted from the electronic health record based on discrete observations, ICD9/10 codes, and RxNorm codes for antihypertensives. Results Among survivors (n = 731), 10 incident cases (1.4%) of CVD were observed between one year and five years after the initial diagnosis. Public health insurance (p = 0.04) and late effects risk strata (p = 0.01) were positively associated with CVD. Among survivors with public insurance(n = 495), two additional cases of CVD were identified from claims data with an incidence of 2.4%. Survivors from rural areas had a 4.1 times greater risk of CVD compared with survivors from urban areas (95% CI: 1.1-15.3), despite adjustment for late effects risk strata. Conclusions Clinically computable phenotypes for CVRFs among survivors through informatics methods were feasible. Although CVRFs were not associated with CVD in the early survivorship period, survivors from rural areas were more likely to develop CVD. Implications for Survivors Survivors from non-urban areas and those with public insurance may be particularly vulnerable to CVD.
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Affiliation(s)
- David H Noyd
- Seattle Children's Hospital/University of Washington Department of Pediatrics
| | - Anna Bailey
- The University of Oklahoma Health Sciences Center, Hudson College of Public Health, Department of Biostatistics and Epidemiology
| | - Amanda Janitz
- The University of Oklahoma Health Sciences Center, Hudson College of Public Health, Department of Biostatistics and Epidemiology
| | - Talayeh Razzaghi
- The University of Oklahoma, School of Industrial and Systems Engineering
| | - Sharon Bouvette
- The University of Oklahoma Health Sciences Center, College of Medicine
| | - William Beasley
- The University of Oklahoma Health Sciences Center, College of Medicine
| | - Ashley Baker
- The University of Oklahoma Health Sciences Center, College of Medicine
| | - Sixia Chen
- The University of Oklahoma Health Sciences Center, Hudson College of Public Health, Department of Biostatistics and Epidemiology
| | - David Bard
- The University of Oklahoma Health Sciences Center, College of Medicine
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5
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Chen Y, Shen Y, Zhang H, Wang X, Xu Y, Zhang J, Zhao W, Zhao R, Liu Z, Cheng L, Ge J. Inflammatory Reprogramming Mediates Changes in Three-Dimensional Strain Capacity and Cardiac Function in Beagle Dogs with Doxorubicin-Related Cardiomyopathy. Rev Cardiovasc Med 2024; 25:62. [PMID: 39077361 PMCID: PMC11263182 DOI: 10.31083/j.rcm2502062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/21/2023] [Accepted: 10/19/2023] [Indexed: 07/31/2024] Open
Abstract
Background The cardiotoxicity of doxorubicin (DOX) limits its use in cancer treatment. To address this limitation, we developed a novel animal model that uses beagle dogs to investigate DOX-induced cardiac disorders. Unfortunately, the lack of effective cardioprotection strategies against DOX-induced cardiotoxicity poses a significant challenge. To establish a canine model for low-mortality DOX-induced cardiac dysfunction and explore the relationship between inflammatory reprogramming and DOX-related cardiotoxicity. Methods Twenty male beagle dogs aged two years were randomly assigned into the DOX (N = 10) and control (CON) (N = 10) groups. DOX was infused (1.5 mg/kg) every two weeks until doses cumulatively reached 12 mg/kg. Serum biomarkers and myocardial pathology were evaluated, while real-time fluorescence-based quantitative polymerase chain reaction (RTFQ-PCR), two- and three-dimensional echocardiography (2DE and RT3DE), functional enrichment, and matrix correlation were also performed. Results In the DOX group, high-sensitive cardiac troponin T (hs cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were significantly increased. Myocardial pathology indicated early to medium myocardial degeneration via a decreased cardiomyocyte cross-sectional area (CSA). Increased levels of inflammatory gene transcripts (interleukin 6 (IL6), tumor necrosis factor (TNF), transforming growth factor β (TGF β ), intercellular adhesion molecule 1 (ICAM1), interleukin 1 (IL1), interleukin 1 β (IL1 β ), and interleukin 8 (IL8)), of collagen metabolism and deposition regulatory genes (matrix metalloproteinase (MMP) family and tissue inhibitor of matrix metalloproteinase (TIMP) family), and the natriuretic peptide family (NPS) (natriuretic peptide A, B and C (NPPA, NPPB, and NPPC)) were observed. Strain abnormalities in the right ventricular longitudinal septal strain (RVLSS), right ventricular longitudinal free-wall strain (RVLFS), left ventricular global longitudinal strain (LVGLS), and left ventricular global circumferential strain (LVGCS) were detected at week 28 (vs. week 0 or CON group, p < 0.05, respectively). A significant decline in RVLSS and RVLFS occurred at week 16, which was earlier than in the corresponding left ventricular areas. A significant right ventricular ejection fraction (RVEF) decline was noted at week 16 (vs. week 0, 33.92 ± 3.59% vs. 38.58 ± 3.58%, p < 0.05), which was 12 weeks earlier than for the left ventricular ejection fraction (LVEF), which occurred at week 28 (vs. week 0, 49.02 ± 2.07% vs. 54.26 ± 4.38%, p < 0.01). The right ventricular strain and functional damages correlated stronger with inflammatory reprogramming (most R from 0.60 to 0.90) than the left ones (most R from 0.30 to 0.65), thereby indicating a more pronounced correlation. Conclusions Inflammatory reprogramming mediated disorders of strain capacity and cardiac function predominantly in the right side of the heart in the newly established DOX-related cardiomyopathy beagle dog model.
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Affiliation(s)
- Yifan Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Key Laboratory of Viral Heart Diseases, National Health Commission, 200032 Shanghai, China
| | - Yihui Shen
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, 200032 Shanghai, China
| | - Hui Zhang
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, 200032 Shanghai, China
| | - Xuejun Wang
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, 200032 Shanghai, China
| | - Yuchen Xu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Key Laboratory of Viral Heart Diseases, National Health Commission, 200032 Shanghai, China
| | - Jian Zhang
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, 200032 Shanghai, China
| | - Weiguang Zhao
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 200080 Shanghai, China
| | - Rui Zhao
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, 200032 Shanghai, China
| | - Zhihong Liu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 200080 Shanghai, China
| | - Leilei Cheng
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, 200032 Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Key Laboratory of Viral Heart Diseases, National Health Commission, 200032 Shanghai, China
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Leerink JM, Feijen EAM. Secondary prevention of anthracycline cardiotoxicity in childhood cancer survivors. Lancet Oncol 2024; 25:154-156. [PMID: 38215763 DOI: 10.1016/s1470-2045(24)00001-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/02/2024] [Indexed: 01/14/2024]
Affiliation(s)
- Jan M Leerink
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, Netherlands; Princess Maxima Medical Center, Utrecht, Netherlands.
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Bisceglia I, Canale ML, Silvestris N, Gallucci G, Camerini A, Inno A, Camilli M, Turazza FM, Russo G, Paccone A, Mistrulli R, De Luca L, Di Fusco SA, Tarantini L, Lucà F, Oliva S, Moreo A, Maurea N, Quagliariello V, Ricciardi GR, Lestuzzi C, Fiscella D, Parrini I, Racanelli V, Russo A, Incorvaia L, Calabrò F, Curigliano G, Cinieri S, Gulizia MM, Gabrielli D, Oliva F, Colivicchi F. Cancer survivorship at heart: a multidisciplinary cardio-oncology roadmap for healthcare professionals. Front Cardiovasc Med 2023; 10:1223660. [PMID: 37786510 PMCID: PMC10541962 DOI: 10.3389/fcvm.2023.1223660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/24/2023] [Indexed: 10/04/2023] Open
Abstract
In cancer, a patient is considered a survivor from the time of initial diagnosis until the end of life. With improvements in early diagnosis and treatment, the number of cancer survivors (CS) has grown considerably and includes: (1) Patients cured and free from cancer who may be at risk of late-onset cancer therapy-related cardiovascular toxicity (CTR-CVT); (2) Patients with long-term control of not-curable cancers in whom CTR-CVT may need to be addressed. This paper highlights the importance of the cancer care continuum, of a patient-centered approach and of a prevention-oriented policy. The ultimate goal is a personalized care of CS, achievable only through a multidisciplinary-guided survivorship care plan, one that replaces the fragmented management of current healthcare systems. Collaboration between oncologists and cardiologists is the pillar of a framework in which primary care providers and other specialists must be engaged and in which familial, social and environmental factors are also taken into account.
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Affiliation(s)
- Irma Bisceglia
- Integrated Cardiology Services, Cardio-Thoracic-Vascular Department, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Maria Laura Canale
- Division of Cardiology, Ospedale Versilia, Azienda Usl Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Nicola Silvestris
- Unit of Medical Oncology, Department of Human Pathology in Adulthood and Childhood Gaetano Barresi, University of Messina, Messina, Italy
| | - Giuseppina Gallucci
- Cardio-oncology Unit, Department of OncoHaematology, IRCCS Referral Cancer Center of Basilicata, Rionero in Vulture (PZ), Italy
| | - Andrea Camerini
- Department of Medical Oncology, Ospedale Versilia, Azienda Usl Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Alessandro Inno
- Department of Oncology, Sacro Cuore Don Calabria Hospital (IRCCS), Negrar, Italy
| | - Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart and Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabio Maria Turazza
- Cardiology Department, National Cancer Institute Foundation (IRCCS), Milan, Italy
| | - Giulia Russo
- SC Patologie Cardiovascolari, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Trieste, Italy
| | - Andrea Paccone
- Department of Cardiology, G. Pascale National Cancer Institute Foundation (IRCCS), Naples, Italy
| | - Raffaella Mistrulli
- Cardiology Unit, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Lazio, Italy
| | - Leonardo De Luca
- Division of Cardiology, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Luigi Tarantini
- Divisione di Cardiologia, Arcispedale S. Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio-Emilia, Reggio Emilia, Italy
| | - Fabiana Lucà
- Cardiologia Interventistica, Utic, Grande Ospedale Metropolitano, Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Stefano Oliva
- UOSD Cardiologia di Interesse Oncologico, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Antonella Moreo
- Cardio Center De Gasperis, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nicola Maurea
- Department of Cardiology, G. Pascale National Cancer Institute Foundation (IRCCS), Naples, Italy
| | - Vincenzo Quagliariello
- Department of Cardiology, G. Pascale National Cancer Institute Foundation (IRCCS), Naples, Italy
| | | | | | - Damiana Fiscella
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Iris Parrini
- Department of Cardiology, Hospital Mauritian Turin, Turin, Italy
| | - Vito Racanelli
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Antonio Russo
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, Palermo University Hospital, Palermo, Italy
| | - Lorena Incorvaia
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, Palermo University Hospital, Palermo, Italy
| | - Fabio Calabrò
- Department of Oncology and Specialized Medicine, San Camillo-Forlanini Hospital, Rome, Italy
| | - Giuseppe Curigliano
- Department of Oncology and Hemato-Oncology, University of Milan; Division of Early Drug Development, Istituto Europeo di Oncologia, IRCCS, Milan, Italy
| | - Saverio Cinieri
- Medical Oncology Division and Breast Unit, Senatore Antonio Perrino Hospital, ASL Brindisi, Brindisi, Italy
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Domenico Gabrielli
- Division of Cardiology, San Camillo-Forlanini Hospital, Rome, Italy
- Fondazione per il Tuo cuore- Heart Care Foundation, Firenze, Italy
| | - Fabrizio Oliva
- Cardiologia 1- Emodinamica, Dipartimento Cardiotoracovascolare “A. De Gasperis”, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Unit, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
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8
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Antoniadi K, Thomaidis N, Nihoyannopoulos P, Toutouzas K, Gikas E, Kelaidi C, Polychronopoulou S. Prognostic Factors for Cardiotoxicity among Children with Cancer: Definition, Causes, and Diagnosis with Omics Technologies. Diagnostics (Basel) 2023; 13:1864. [PMID: 37296716 PMCID: PMC10252297 DOI: 10.3390/diagnostics13111864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/03/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Improvements in the treatment of childhood cancer have considerably enhanced survival rates over the last decades to over 80% as of today. However, this great achievement has been accompanied by the occurrence of several early and long-term treatment-related complications major of which is cardiotoxicity. This article reviews the contemporary definition of cardiotoxicity, older and newer chemotherapeutic agents that are mainly involved in cardiotoxicity, routine process diagnoses, and methods using omics technology for early and preventive diagnosis. Chemotherapeutic agents and radiation therapies have been implicated as a cause of cardiotoxicity. In response, the area of cardio-oncology has developed into a crucial element of oncologic patient care, committed to the early diagnosis and treatment of adverse cardiac events. However, routine diagnosis and the monitoring of cardiotoxicity rely on electrocardiography and echocardiography. For the early detection of cardiotoxicity, in recent years, major studies have been conducted using biomarkers such as troponin, N-terminal pro b-natriuretic peptide, etc. Despite the refinements in diagnostics, severe limitations still exist due to the increase in the above-mentioned biomarkers only after significant cardiac damage has occurred. Lately, the research has expanded by introducing new technologies and finding new markers using the omics approach. These new markers could be used not only for early detection but also for the early prevention of cardiotoxicity. Omics science, which includes genomics, transcriptomics, proteomics, and metabolomics, offers new opportunities for biomarker discovery in cardiotoxicity and may provide an understanding of the mechanisms of cardiotoxicity beyond traditional technologies.
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Affiliation(s)
- Kondylia Antoniadi
- Department of Pediatric Hematology-Oncology (T.A.O.), “Aghia Sophia” Children’s Hospital, Goudi, 11527 Athens, Greece
| | - Nikolaos Thomaidis
- Department of Chemistry, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Petros Nihoyannopoulos
- First Department of Cardiology, University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Evangelos Gikas
- Department of Chemistry, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Charikleia Kelaidi
- Department of Pediatric Hematology-Oncology (T.A.O.), “Aghia Sophia” Children’s Hospital, Goudi, 11527 Athens, Greece
| | - Sophia Polychronopoulou
- Department of Pediatric Hematology-Oncology (T.A.O.), “Aghia Sophia” Children’s Hospital, Goudi, 11527 Athens, Greece
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9
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Joolharzadeh P, Rodriguez M, Zaghlol R, Pedersen LN, Jimenez J, Bergom C, Mitchell JD. Recent Advances in Serum Biomarkers for Risk Stratification and Patient Management in Cardio-Oncology. Curr Cardiol Rep 2023; 25:133-146. [PMID: 36790618 PMCID: PMC9930715 DOI: 10.1007/s11886-022-01834-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 02/16/2023]
Abstract
PURPOSE OF REVIEW Following significant advancements in cancer therapeutics and survival, the risk of cancer therapy-related cardiotoxicity (CTRC) is increasingly recognized. With ongoing efforts to reduce cardiovascular morbidity and mortality in cancer patients and survivors, cardiac biomarkers have been studied for both risk stratification and monitoring during and after therapy to detect subclinical disease. This article will review the utility for biomarker use throughout the cancer care continuum. RECENT FINDINGS A recent meta-analysis shows utility for troponin in monitoring patients at risk for CTRC during cancer therapy. The role for natriuretic peptides is less clear but may be useful in patients receiving proteasome inhibitors. Early studies explore use of myeloperoxidase, growth differentiation factor 15, galectin 3, micro-RNA, and others as novel biomarkers in CTRC. Biomarkers have potential to identify subclinical CTRC and may reveal opportunities for early intervention. Further research is needed to elucidate optimal biomarkers and surveillance strategies.
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Affiliation(s)
- Pouya Joolharzadeh
- General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Mario Rodriguez
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Raja Zaghlol
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Lauren N Pedersen
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jesus Jimenez
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Carmen Bergom
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Joshua D Mitchell
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA.
- Alvin J. Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA.
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10
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Ehrhardt MJ, Leerink JM, Mulder RL, Mavinkurve-Groothuis A, Kok W, Nohria A, Nathan PC, Merkx R, de Baat E, Asogwa OA, Skinner R, Wallace H, Lieke Feijen EAM, de Ville de Goyet M, Prasad M, Bárdi E, Pavasovic V, van der Pal H, Fresneau B, Demoor-Goldschmidt C, Hennewig U, Steinberger J, Plummer C, Chen MH, Teske AJ, Haddy N, van Dalen EC, Constine LS, Chow EJ, Levitt G, Hudson MM, Kremer LCM, Armenian SH. Systematic review and updated recommendations for cardiomyopathy surveillance for survivors of childhood, adolescent, and young adult cancer from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2023; 24:e108-e120. [PMID: 37052966 DOI: 10.1016/s1470-2045(23)00012-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/07/2022] [Accepted: 01/10/2023] [Indexed: 02/16/2023]
Abstract
Survivors of childhood, adolescent, and young adult cancer, previously treated with anthracycline chemotherapy (including mitoxantrone) or radiotherapy in which the heart was exposed, are at increased risk of cardiomyopathy. Symptomatic cardiomyopathy is typically preceded by a series of gradually progressive, asymptomatic changes in structure and function of the heart that can be ameliorated with treatment, prompting specialist organisations to endorse guidelines on cardiac surveillance in at-risk survivors of cancer. In 2015, the International Late Effects of Childhood Cancer Guideline Harmonization Group compiled these guidelines into a uniform set of recommendations applicable to a broad spectrum of clinical environments with varying resource availabilities. Since then, additional studies have provided insight into dose thresholds associated with a risk of asymptomatic and symptomatic cardiomyopathy, have characterised risk over time, and have established the cost-effectiveness of different surveillance strategies. This systematic Review and guideline provides updated recommendations based on the evidence published up to September, 2020.
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11
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Aziz-Bose R, Armenian SH, Nohria A, Kenney LB. REPLY: Novel Technologies Must Be Considered for Childhood Cancer Survivors at Risk for Cardiomyopathy. JACC CardioOncol 2023; 5:157. [PMID: 36875896 PMCID: PMC9982201 DOI: 10.1016/j.jaccao.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Affiliation(s)
- Rahela Aziz-Bose
- Dana-Farber Cancer Institute, 450 Brookline Avenue, SW 311, Boston, Massachusetts 02215, USA
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12
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 816] [Impact Index Per Article: 408.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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13
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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14
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Bergler-Klein J, Rainer PP, Wallner M, Zaruba MM, Dörler J, Böhmer A, Buchacher T, Frey M, Adlbrecht C, Bartsch R, Gyöngyösi M, Fürst UM. Cardio-oncology in Austria: cardiotoxicity and surveillance of anti-cancer therapies : Position paper of the Heart Failure Working Group of the Austrian Society of Cardiology. Wien Klin Wochenschr 2022; 134:654-674. [PMID: 35507087 PMCID: PMC9065248 DOI: 10.1007/s00508-022-02031-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/18/2022] [Indexed: 02/07/2023]
Abstract
Survival in cancer is continuously improving due to evolving oncological treatment. Therefore, cardiovascular short-term and long-term side effects gain crucial importance for overall outcome. Cardiotoxicity not only presents as heart failure, but also as treatment-resistant hypertension, acute coronary ischemia with plaque rupture or vasospasm, thromboembolism, arrhythmia, pulmonary hypertension, diastolic dysfunction, acute myocarditis and others. Recent recommendations have proposed baseline cardiac risk assessment and surveillance strategies. Major challenges are the availability of monitoring and imaging resources, including echocardiography with speckle tracking longitudinal strain (GLS), serum biomarkers such as natriuretic peptides (NT-proBNP) and highly sensitive cardiac troponins. This Austrian consensus encompasses cardiotoxicity occurrence in frequent antiproliferative cancer drugs, radiotherapy, immune checkpoint inhibitors and cardiac follow-up considerations in cancer survivors in the context of the Austrian healthcare setting. It is important to optimize cardiovascular risk factors and pre-existing cardiac diseases without delaying oncological treatment. If left ventricular ejection fraction (LVEF) deteriorates during cancer treatment (from >10% to <50%), or myocardial strain decreases (>15% change in GLS), early initiation of cardioprotective therapies (angiotensin-converting enzyme inhibitors, angiotensin or beta receptor blockers) is recommended, and LVEF should be reassessed before discontinuation. Lower LVEF cut-offs were recently shown to be feasible in breast cancer patients to enable optimal anticancer treatment. Interdisciplinary cardio-oncology cooperation is pivotal for optimal management of cancer patients.
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Affiliation(s)
- Jutta Bergler-Klein
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz, Austria.,BioTechMed Graz, Graz, Austria
| | - Markus Wallner
- Division of Cardiology, Medical University of Graz, Graz, Austria.,Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Marc-Michael Zaruba
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Dörler
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria.,Department of Internal Medicine and Cardiology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Armin Böhmer
- Department of Internal Medicine 1, Krems University Clinic, Krems, Austria
| | - Tamara Buchacher
- Department of Internal Medicine and Cardiology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Maria Frey
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | | | - Rupert Bartsch
- Department of Medicine 1, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Mariann Gyöngyösi
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ursula-Maria Fürst
- Department of Internal Medicine, Hospital of the Brothers of St. John of God (Krankenhaus Barmherzige Brüder) Salzburg, Salzburg, Austria
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15
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Amedro P, Vincenti M, Abassi H, Lanot N, De La Villeon G, Guillaumont S, Gamon L, Mura T, Lopez-Perrin K, Haouy S, Sirvent A, Cazorla O, Vergely L, Lacampagne A, Avesani M, Sirvent N, Saumet L. Use of speckle tracking echocardiography to detect late anthracycline-induced cardiotoxicity in childhood cancer: A prospective controlled cross-sectional study. Int J Cardiol 2022; 354:75-83. [DOI: 10.1016/j.ijcard.2022.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/09/2022] [Accepted: 02/10/2022] [Indexed: 01/10/2023]
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16
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Reiner B, Schmid I, Schulz T, Müller J, Hager A, Hock J, Ewert P, Wolf C, Oberhoffer-Fritz R, Weil J. Cardiovascular Function and Exercise Capacity in Childhood Cancer Survivors. J Clin Med 2022; 11:jcm11030628. [PMID: 35160079 PMCID: PMC8837025 DOI: 10.3390/jcm11030628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/15/2022] [Accepted: 01/19/2022] [Indexed: 12/10/2022] Open
Abstract
Introduction: Childhood cancer survivors (CCS) might be at high risk of additional chronic diseases due to cardiotoxic side effects. The aim of this study was to analyze long-term side effects of cancer therapy on vascular structure/function, cardiac biomarkers and on physical activity. Methods: In total, 68 asymptomatic patients aged 16–30 years with childhood cancer (diagnosed 10.6 ± 3.9 years ago) were examined from 2015–2020. (Central) blood pressure and pulse wave velocity were registered via the oscillometric method, while carotid intima-media thickness (cIMT) was measured non-invasively by ultrasound. cIMT values of patients were compared to healthy controls (n = 68; aged 22.3 ± 3.5 years). Patients’ exercise capacity was recorded. The plasma N-terminal pro-brain natriuretic protein (NTproBNP) and troponin levels were measured as cardiac biomarkers. CCS were categorized in groups with low, moderate and high anthracyclines. Results: No differences were found in cIMT between patients and controls as well as between patients with various anthracycline dosage. Patients with high dose anthracyclines showed a significant lower performance versus patients with moderate dose anthracyclines (84.4% of predicted VO2peak; p = 0.017). A total of 11.6% of CCS had abnormal NTproBNP values which correlated with received anthracycline dosage (p = 0.024; r = 0.343). Conclusion: NTproBNP levels and exercise capacity might be early markers for cardiovascular dysfunction in CCS and should be included in a follow-up protocol, while cIMT and troponin seem not to be adequate parameters.
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Affiliation(s)
- Barbara Reiner
- Institute of Preventive Pediatrics, Technical University Munich, 80992 Munich, Germany; (T.S.); (J.M.); (R.O.-F.)
- Correspondence: ; Tel.: +49-89-289-24900
| | - Irene Schmid
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital Munich, LMU Munich, 80337 Munich, Germany;
| | - Thorsten Schulz
- Institute of Preventive Pediatrics, Technical University Munich, 80992 Munich, Germany; (T.S.); (J.M.); (R.O.-F.)
| | - Jan Müller
- Institute of Preventive Pediatrics, Technical University Munich, 80992 Munich, Germany; (T.S.); (J.M.); (R.O.-F.)
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, 80636 Munich, Germany; (A.H.); (J.H.); (P.E.); (C.W.); (J.W.)
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, 80636 Munich, Germany; (A.H.); (J.H.); (P.E.); (C.W.); (J.W.)
| | - Julia Hock
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, 80636 Munich, Germany; (A.H.); (J.H.); (P.E.); (C.W.); (J.W.)
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, 80636 Munich, Germany; (A.H.); (J.H.); (P.E.); (C.W.); (J.W.)
| | - Cordula Wolf
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, 80636 Munich, Germany; (A.H.); (J.H.); (P.E.); (C.W.); (J.W.)
| | - Renate Oberhoffer-Fritz
- Institute of Preventive Pediatrics, Technical University Munich, 80992 Munich, Germany; (T.S.); (J.M.); (R.O.-F.)
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, 80636 Munich, Germany; (A.H.); (J.H.); (P.E.); (C.W.); (J.W.)
| | - Jochen Weil
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, 80636 Munich, Germany; (A.H.); (J.H.); (P.E.); (C.W.); (J.W.)
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17
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Mitchell JD, Cehic DA, Morgia M, Bergom C, Toohey J, Guerrero PA, Ferencik M, Kikuchi R, Carver JR, Zaha VG, Alvarez-Cardona JA, Szmit S, Daniele AJ, Lopez-Mattei J, Zhang L, Herrmann J, Nohria A, Lenihan DJ, Dent SF. Cardiovascular Manifestations From Therapeutic Radiation: A Multidisciplinary Expert Consensus Statement From the International Cardio-Oncology Society. JACC: CARDIOONCOLOGY 2021; 3:360-380. [PMID: 34604797 PMCID: PMC8463721 DOI: 10.1016/j.jaccao.2021.06.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 01/09/2023]
Abstract
Radiation therapy is a cornerstone of cancer therapy, with >50% of patients undergoing therapeutic radiation. As a result of widespread use and improved survival, there is increasing focus on the potential long-term effects of ionizing radiation, especially cardiovascular toxicity. Radiation therapy can lead to atherosclerosis of the vasculature as well as valvular, myocardial, and pericardial dysfunction. We present a consensus statement from the International Cardio-Oncology Society based on general principles of radiotherapy delivery and cardiovascular risk assessment and risk mitigation in this population. Anatomical-based recommendations for cardiovascular management and follow-up are provided, and a priority is given to the early detection of atherosclerotic vascular disease on imaging to help guide preventive therapy. Unique management considerations in radiation-induced cardiovascular disease are also discussed. Recommendations are based on the most current literature and represent a unanimous consensus by the multidisciplinary expert panel. Radiation therapy leads to short- and long-term cardiovascular adverse effects of the vasculature and the heart, including valvular, myocardial, and pericardial disease. Computed tomography scans conducted for radiation planning or cancer staging provide an available opportunity to detect asymptomatic atherosclerosis and direct preventive therapies. Additional practical screening recommendations for cardiovascular disease based on anatomical exposure are provided. There are unique considerations in the management of radiation-induced cardiovascular disease; contemporary percutaneous treatment is often preferred over surgical options.
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Key Words
- CABG, coronary artery bypass graft
- CAC, coronary artery calcium
- CAD, coronary artery disease
- CI, confidence interval
- CT, computed tomography
- CTCA, computed tomography coronary angiography
- CV, cardiovascular
- DIBH, deep inspiratory breath hold
- HF, heart failure
- HL, Hodgkin lymphoma
- HNC, head and neck cancer
- HR, hazard ratio
- LIMA, left internal mammary artery
- MRI, magnetic resonance imaging
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- OR, odds ratio
- PAD, peripheral arterial disease
- RT, radiation therapy
- SAVR, surgical aortic valve replacement
- SVC, superior vena cava
- TAVR, transcatheter aortic valve replacement
- TTE, transthoracic echocardiogram
- aHR, adjusted hazard ratio
- cancer
- cardiovascular disease
- imaging
- prevention
- radiation therapy
- screening
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Affiliation(s)
- Joshua D. Mitchell
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, Missouri, USA
- Address for correspondence: Dr Joshua D. Mitchell, Cardio-Oncology Center of Excellence, Washington University in St Louis, 660 South Euclid Avenue, Campus Box 8086, St. Louis, Missouri 63110-1093, USA. @joshmitchellmd@Dr_Daniel_Cehic@carmenbergom@ICOSociety
| | | | - Marita Morgia
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Carmen Bergom
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joanne Toohey
- Department of Radiation Oncology, GenesisCare, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Robin Kikuchi
- Division of Medical Oncology, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Joseph R. Carver
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vlad G. Zaha
- Cardiology Division, Department of Internal Medicine, Harold C. Simmons Comprehensive Cancer Center, Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Parkland Health and Hospital System, Dallas, Texas, USA
| | - Jose A. Alvarez-Cardona
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Sebastian Szmit
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | | | - Juan Lopez-Mattei
- Departments of Cardiology and Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lili Zhang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jörg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Anju Nohria
- Cardio-Oncology Program, Dana Farber Cancer Institute/Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Daniel J. Lenihan
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Susan F. Dent
- Division of Medical Oncology, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
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18
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Bergom C, Bradley JA, Ng AK, Samson P, Robinson C, Lopez-Mattei J, Mitchell JD. Past, Present, and Future of Radiation-Induced Cardiotoxicity: Refinements in Targeting, Surveillance, and Risk Stratification. JACC CardioOncol 2021; 3:343-359. [PMID: 34604796 PMCID: PMC8463722 DOI: 10.1016/j.jaccao.2021.06.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 12/13/2022] Open
Abstract
Radiation therapy is an important component of cancer therapy for many malignancies. With improvements in cardiac-sparing techniques, radiation-induced cardiac dysfunction has decreased but remains a continued concern. In this review, we provide an overview of the evolution of radiotherapy techniques in thoracic cancers and associated reductions in cardiac risk. We also highlight data demonstrating that in some cases radiation doses to specific cardiac substructures correlate with cardiac toxicities and/or survival beyond mean heart dose alone. Advanced cardiac imaging, cardiovascular risk assessment, and potentially even biomarkers can help guide post-radiotherapy patient care. In addition, treatment of ventricular arrhythmias with the use of ablative radiotherapy may inform knowledge of radiation-induced cardiac dysfunction. Future efforts should explore further personalization of radiotherapy to minimize cardiac dysfunction by coupling knowledge derived from enhanced dosimetry to cardiac substructures, post-radiation regional dysfunction seen on advanced cardiac imaging, and more complete cardiac toxicity data.
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Key Words
- CAC, coronary artery calcium
- CAD, coronary artery disease
- CMRI, cardiac magnetic resonance imaging
- CT, computed tomography
- HL, Hodgkin lymphoma
- LAD, left anterior descending artery
- LV, left ventricular
- MHD, mean heart dose
- NSCLC, non–small cell lung cancer
- RICD, radiation-induced cardiovascular disease
- RT, radiation therapy
- SBRT, stereotactic body radiation therapy
- breast cancer
- cancer survivorship
- childhood cancer
- esophageal cancer
- imaging
- lung cancer
- lymphoma
- radiation physics
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Affiliation(s)
- Carmen Bergom
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri, USA
- Cardio-Oncology Center of Excellence, Washington University, St. Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - Andrea K. Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Pamela Samson
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
- Division of Cardiology, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Juan Lopez-Mattei
- Departments of Cardiology and Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joshua D. Mitchell
- Cardio-Oncology Center of Excellence, Washington University, St. Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
- Division of Cardiology, Department of Medicine, Washington University, St. Louis, Missouri, USA
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19
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Patel SR, Herrmann J, Vierkant RA, Olson JE, Couch FJ, Hazim A, Sloan JA, Loprinzi CL, Ruddy KJ. N-Terminal Pro Brain Natriuretic Peptide, sST2, and Galectin-3 Levels in Breast Cancer Survivors. J Clin Med 2021; 10:3313. [PMID: 34362097 PMCID: PMC8346981 DOI: 10.3390/jcm10153313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/17/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023] Open
Abstract
NT-proBNP, soluble ST2 (sST2), and galectin-3 are biomarkers of cardiac dysfunction that have been proposed as identifiers of patients experiencing asymptomatic cardiac dysfunction after anthracycline-based chemotherapy. This study aimed to compare the proportion of breast cancer (BC) survivors with elevated serum levels of these three putative biomarkers by prior receipt of anthracycline (yes vs. no). Five-hundred-eighty survivors of BC who had received anthracycline-based chemotherapy were matched by age and time between diagnosis and serum storage to 580 who had not. Cardiac biomarker levels were analyzed using immunoassays. Analyses were carried out using linear and logistic regression models. Anthracycline recipients had higher values of NT-proBNP than non-recipients (mean 116.0 ng/L vs. 97.0 ng/L, respectively; p < 0.001). Values for ST2 and galectin-3 did not significantly differ by receipt of anthracycline. After further adjustment for age at breast cancer diagnosis, ethnicity, and receipt of trastuzumab, associations between receipt of anthracycline and higher NT-proBNP persisted (p < 0.001), showing that NT-proBNP may be a biomarker of cardiovascular toxicity after receipt of anthracycline-based chemotherapy. Further research to assess the clinical utility of NT-proBNP testing after receipt of anthracycline is recommended. sST2 and galectin-3 do not appear to differentiate between anthracycline recipients and non-recipients amongst breast cancer survivors.
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Affiliation(s)
| | - Joerg Herrmann
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN 55901, USA;
| | - Robert A. Vierkant
- Health Sciences Research, Mayo Clinic, Rochester, MN 55901, USA; (R.A.V.); (J.E.O.); (J.A.S.)
| | - Janet E. Olson
- Health Sciences Research, Mayo Clinic, Rochester, MN 55901, USA; (R.A.V.); (J.E.O.); (J.A.S.)
| | - Fergus J. Couch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55901, USA;
| | - Antonious Hazim
- Department of Internal Medicine, Mayo Clinic, Rochester, MN 55901, USA;
| | - Jeff A. Sloan
- Health Sciences Research, Mayo Clinic, Rochester, MN 55901, USA; (R.A.V.); (J.E.O.); (J.A.S.)
| | - Charles L. Loprinzi
- Department of Oncology, Mayo Clinic, Rochester, MN 55901, USA; (C.L.L.); (K.J.R.)
| | - Kathryn J. Ruddy
- Department of Oncology, Mayo Clinic, Rochester, MN 55901, USA; (C.L.L.); (K.J.R.)
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