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Fernandez-Aviles C, Gonzalez-Manzanares R, Ojeda S, Castillo JC, Robles-Mezcua A, Anguita M, Mesa D, Pan M. Diagnostic and Therapeutic Approaches for Heart Failure in Long-Term Survivors of Childhood Cancer. Biomedicines 2024; 12:1875. [PMID: 39200339 PMCID: PMC11351207 DOI: 10.3390/biomedicines12081875] [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: 06/30/2024] [Revised: 08/05/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
The improvement in survival rates in pediatric malignancies has led to an increase in the number of cancer survivors who are at risk of developing cardiotoxicity and heart failure. Cardiac dysfunction in these patients can occur asymptomatically, and the diagnosis in a symptomatic phase is associated with reduced treatment response and worse prognosis. For this reason, it is essential to establish protocols to follow up on these patients and identify those at risk of cardiotoxicity in order to start early and effective therapies. This review aims to summarize the latest findings in the diagnosis and treatment of cancer therapy-related cardiac disease in long-term survivors of childhood cancer, with a focus on heart failure.
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Affiliation(s)
- Consuelo Fernandez-Aviles
- Cardiology Unit, Reina Sofía University Hospital, 14004 Córdoba, Spain (M.P.)
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain
| | - Rafael Gonzalez-Manzanares
- Cardiology Unit, Reina Sofía University Hospital, 14004 Córdoba, Spain (M.P.)
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Soledad Ojeda
- Cardiology Unit, Reina Sofía University Hospital, 14004 Córdoba, Spain (M.P.)
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba, 14004 Córdoba, Spain
| | - Juan C. Castillo
- Cardiology Unit, Reina Sofía University Hospital, 14004 Córdoba, Spain (M.P.)
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Ainhoa Robles-Mezcua
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Cardiology Unit, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain
- IBIMA-Plataforma BIONAND, Universidad de Málaga, 29071 Málaga, Spain
| | - Manuel Anguita
- Cardiology Unit, Reina Sofía University Hospital, 14004 Córdoba, Spain (M.P.)
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Dolores Mesa
- Cardiology Unit, Reina Sofía University Hospital, 14004 Córdoba, Spain (M.P.)
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Manuel Pan
- Cardiology Unit, Reina Sofía University Hospital, 14004 Córdoba, Spain (M.P.)
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba, 14004 Córdoba, Spain
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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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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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Development and Validation of a Diagnostic Nomogram to Predict the Anthracycline-Induced Early Cardiotoxicity in Children with Hematological Tumors. Cardiovasc Toxicol 2022; 22:802-812. [PMID: 35708895 PMCID: PMC9381481 DOI: 10.1007/s12012-022-09755-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/25/2022] [Indexed: 11/03/2022]
Abstract
This study aimed to establish and validate an effective nomogram to predict the risk of cardiotoxicity in children after each anthracycline treatment. According to the inclusion and exclusion criteria, the eligible children were randomly divided into the training cohort (75%) and the validation cohort (25%). Least absolute shrinkage and selection operator (LASSO) regression was used to select the predictors and a nomogram was developed. Then, concordance index (C-index), the area under the curve (AUC), Hosmer-Lemeshow (H-L) test, and decision curve analysis (DCA) were employed to evaluate the performance and clinical utility of nomogram. Internal validation was processed to inspect the stability of the model. A total of 796 eligible children were included in this study and divided into a training set (n = 597) and a validation set (n = 199). LASSO regression analysis revealed that cumulative anthracycline dose, ejection fractions, NT-proBNP, and diastolic dysfunction were effective predictors of cardiotoxicity. The nomogram was established based on these variables. The C-index and the AUC of the predicting nomogram were 0.818 in the training cohort and 0.773 in the validation cohort, suggesting that the nomogram had good discrimination. The calibration curve of the nomogram presented no significant deviation from the reference line, and the P-value of the H-L test was 0.283, implying a preferable degree of calibration. The threshold of DCA also reflects that the nomogram is clinically useful. A nomogram was developed to predict anthracycline chemotherapy-induced cardiotoxicity in children with hematological tumors. The nomogram has a good prediction effect and can provide a reference for clinicians' diagnosis and treatment.
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Gonzalez-Manzanares R, Castillo JC, Molina JR, Ruiz-Ortiz M, Mesa D, Ojeda S, Anguita M, Pan M. Automated Global Longitudinal Strain Assessment in Long-Term Survivors of Childhood Acute Lymphoblastic Leukemia. Cancers (Basel) 2022; 14:cancers14061513. [PMID: 35326663 PMCID: PMC8946759 DOI: 10.3390/cancers14061513] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 11/16/2022] Open
Abstract
There is limited evidence that supports the use of the global longitudinal strain (GLS) in long-term cardiac monitoring of childhood acute lymphoblastic leukemia survivors (CLSs). Our aim was to assess the utility of automated GLS to detect left ventricular systolic dysfunction (LVSD) in long-term CLSs. Asymptomatic and subclinical LVSD were defined as LVEF < 50% and GLS < 18.5%, respectively. Echocardiographic measurements and biomarkers were compared with a control group. Inverse probability weighting was used to reduce confounding. Regression models were used to identify factors associated with LVEF and GLS in the survivors. Ninety survivors with a median follow-up of 18 (11−26) years were included. The prevalence of LVSD was higher using GLS than with LVEF (26.6% vs. 12.2%). The measurements were both reduced as compared with the controls (p < 0.001). There were no differences in diastolic parameters and NT-ProBNP. Survivors were more likely to have Hs-cTnI levels above the detection limit (40% vs. 17.2%, p = 0.006). The dose of anthracycline was associated with LVEF but not with GLS in the survivors. Biomarkers were not associated with GLS or LVEF. In conclusion, LVSD detection using automated GLS was higher than with LVEF in long-term CLSs. Its incorporation into clinical routine practice may improve the surveillance of these patients.
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Affiliation(s)
- Rafael Gonzalez-Manzanares
- Cardiology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (J.C.C.); (M.R.-O.); (D.M.); (S.O.); (M.A.); (M.P.)
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Correspondence:
| | - Juan C. Castillo
- Cardiology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (J.C.C.); (M.R.-O.); (D.M.); (S.O.); (M.A.); (M.P.)
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), 14004 Cordoba, Spain;
| | - Jose R. Molina
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Hematology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain
| | - Martin Ruiz-Ortiz
- Cardiology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (J.C.C.); (M.R.-O.); (D.M.); (S.O.); (M.A.); (M.P.)
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), 14004 Cordoba, Spain;
| | - Dolores Mesa
- Cardiology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (J.C.C.); (M.R.-O.); (D.M.); (S.O.); (M.A.); (M.P.)
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), 14004 Cordoba, Spain;
| | - Soledad Ojeda
- Cardiology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (J.C.C.); (M.R.-O.); (D.M.); (S.O.); (M.A.); (M.P.)
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Faculty of Medicine and Nursing, University of Cordoba, 14004 Cordoba, Spain
| | - Manuel Anguita
- Cardiology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (J.C.C.); (M.R.-O.); (D.M.); (S.O.); (M.A.); (M.P.)
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), 14004 Cordoba, Spain;
| | - Manuel Pan
- Cardiology Department, Reina Sofia University Hospital, 14004 Cordoba, Spain; (J.C.C.); (M.R.-O.); (D.M.); (S.O.); (M.A.); (M.P.)
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), 14004 Cordoba, Spain;
- Faculty of Medicine and Nursing, University of Cordoba, 14004 Cordoba, Spain
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Kincl V, Panovský R, Kepák T, Bajčiová V, Bednárová V, Opatřil L, Máchal J. Assessment of late cardiotoxic effects in patients treated for cancer in childhood. Cancer Med 2022; 11:1763-1768. [PMID: 35166044 PMCID: PMC9041077 DOI: 10.1002/cam4.4564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/10/2022] [Indexed: 11/10/2022] Open
Abstract
Graphical AbstractThe aim was to assess the late cardiotoxic effects in young adults treated for various cancer types in childhood using echocardiography and 24-h ECG Holter monitoring.
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Affiliation(s)
- Vladimír Kincl
- Department of Internal Medicine/Cardiology, St. Anne's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Roman Panovský
- Department of Internal Medicine/Cardiology, St. Anne's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Tomáš Kepák
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Children's Oncology, University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Viera Bajčiová
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Children's Oncology, University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Veronika Bednárová
- Department of Internal Medicine/Cardiology, St. Anne's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Lukáš Opatřil
- Department of Internal Medicine/Cardiology, St. Anne's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Jan Máchal
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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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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8
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Lapirow D, La Gerche A, Toro C, Masango E, Costello B, Porello E, Ludlow L, Marshall G, Trahair T, Mateos M, Lewin J, Byrne J, Boutros R, Manudhane R, Heath J, Ayer J, Gabriel M, Walwyn T, Saundankar J, Forsey J, Le H, Mason K, Celermajer D, Downie P, Walker R, Holland L, Martin M, McLeman L, Diamond Y, Marcocci M, Donath S, Cheung M, Elliott DA, Conyers R. The Australia and New Zealand Cardio-Oncology Registry: evaluation of chemotherapy-related cardiotoxicity in a national cohort of paediatric cancer patients. Intern Med J 2021; 51:229-234. [PMID: 31841257 DOI: 10.1111/imj.14719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/08/2019] [Accepted: 12/09/2019] [Indexed: 12/22/2022]
Abstract
Cancer therapy related cardiac dysfunction (CTRCD) is an area of increasing focus, particularly during the survivorship period, for paediatric, adolescent and adult cancer survivors. With the advent of immunotherapy and targeted therapy, there is a new set of mechanisms from which paediatric and young adult patients with cancer may suffer cardiovascular injury. Furthermore, cardiovascular disease is the leading cause of morbidity and mortality in the survivorship period. The recently established Australian Cardio-Oncology Registry is the largest and only population-based cardiotoxicity database of paediatric and adolescent and young adult oncology patients in the world, and the first paediatric registry that will document cardiotoxicity caused by chemotherapy and novel targeted therapies using a prospective approach. The database is designed for comprehensive data collection and evaluation of the Australian practice in terms of diagnosis and management of CTRCD. Using the Australian Cardio-Oncology Registry critical clinical information will be collected regarding predisposing factors for the development of CTRCD, the rate of subclinical left ventricular dysfunction and transition to overt heart failure, further research into protectant molecules against cardiac dysfunction and aid in the discovery of which genetic variants predispose to CTRCD. A health economic arm of the study will assess the cost/benefit of both the registry and cardio-oncology clinical implementation. Finally, an imaging arm will establish if exercise cardiac magnetic resonance imaging and VO2 max testing is a more sensitive predictor of cardiac reserve in paediatric and adolescent and young adult oncology patients exposed to cardiac toxic therapies.
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Affiliation(s)
- Daniel Lapirow
- Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andre La Gerche
- Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Cardiac Imaging Research, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Claudia Toro
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Emma Masango
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ben Costello
- Cardiac Imaging Research, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Enzo Porello
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Physiology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Louise Ludlow
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Glenn Marshall
- Department of Pathology, University of New South Wales, Sydney, New South Wales, Australia
| | - Toby Trahair
- Department of Pathology, University of New South Wales, Sydney, New South Wales, Australia
| | - Marion Mateos
- Department of Pathology, University of New South Wales, Sydney, New South Wales, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Jeremy Lewin
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jennifer Byrne
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, The University of Sydney, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Rose Boutros
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Rebecca Manudhane
- The Michael Rice Centre, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - John Heath
- Paediatric Oncology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Julian Ayer
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Melissa Gabriel
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Thomas Walwyn
- Oncology Department, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Jelena Saundankar
- Oncology Department, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Jonathon Forsey
- Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia.,Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Ha Le
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia.,School of Health and Social Development, Deakin University, Melbourne, Victoria, Australia
| | - Kylie Mason
- OnTrac@Petermac, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Clinical Haematology and Bone Marrow Transplant Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Celermajer
- Cardiology Department, The Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Health and Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter Downie
- Children's Cancer Centre, Monash Health, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Roderick Walker
- Oncology Unit, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Lucy Holland
- Oncology Unit, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Michelle Martin
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Lorna McLeman
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Yonatan Diamond
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Maurizio Marcocci
- Chair, My Room Children's Cancer Charity, Melbourne, Victoria, Australia
| | - Susan Donath
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Michael Cheung
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Cardiology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - David A Elliott
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel Conyers
- Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia
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9
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Refining the 10-Year Prediction of Left Ventricular Systolic Dysfunction in Long-Term Survivors of Childhood Cancer. JACC: CARDIOONCOLOGY 2021; 3:62-72. [PMID: 34396306 PMCID: PMC8352242 DOI: 10.1016/j.jaccao.2020.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/11/2020] [Indexed: 12/28/2022]
Abstract
Background In childhood cancer survivors (CCS) at risk for heart failure, echocardiographic surveillance recommendations are currently based on anthracyclines and chest-directed radiotherapy dose. Whether the ejection fraction (EF) measured at an initial surveillance echocardiogram can refine these recommendations is unknown. Objectives The purpose of this study was to assess the added predictive value of EF at >5 years after cancer diagnosis to anthracyclines and chest-directed radiotherapy dose in CCS, for the development of left ventricular dysfunction with an ejection fraction <40% (LVD40). Methods Echocardiographic surveillance was performed in 299 CCS from the Emma Children’s Hospital in the Netherlands. Cox regression models were built including cardiotoxic cancer treatment exposures with and without EF to estimate the probability of LVD40 at 10-year follow-up. Calibration, discrimination, and reclassification were assessed. Results were externally validated in 218 CCS. Results Cumulative incidences of LVD40 at 10-year follow-up were 3.7% and 3.6% in the derivation and validation cohort, respectively. The addition of EF resulted in an integrated area under the curve increase from 0.74 to 0.87 in the derivation cohort and from 0.72 to 0.86 in the validation cohort (likelihood ratio p < 0.001). Reclassification of CCS without LVD40 improved significantly (noncase continuous net reclassification improvement 0.50; 95% confidence interval [CI]: 0.40 to 0.60). A predicted LVD40 probability ≤3%, representing 75% of the CCS, had a negative predictive value of 99% (95% CI: 98% to 100%) for LVD40 within 10 years. However, patients with midrange EF (40% to 49%) at initial screening had an incidence of LVD40 of 11% and a 7.81-fold (95% CI: 2.07- to 29.50-fold) increased risk of LV40 at follow-up. Conclusions In CCS, an initial surveillance EF, in addition to anthracyclines and chest-directed radiotherapy dose, improves the 10-year prediction for LVD40. Through this strategy, both the identification of low-risk survivors in whom the surveillance frequency may be reduced and a group of survivors at increased risk of LVD40 could be identified.
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Abstract
Anthracycline-related cardiomyopathy is of concern in children treated for acute myeloid leukemia (AML). Risk is dose-dependent, increasing with higher doses. We aim to highlight the risk of early-onset cardiotoxicity with low-cumulative anthracycline dose in a young Omani boy with AML. We conclude in the presence of other known risk factors for cardiac dysfunction, there is probably no risk-free anthracycline dose.
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11
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Rubens-Figueroa JD, Cárdenas-Cardós R. Importance of cardio-oncology. How to detect suclinical heart failure. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2021; 91:229-234. [PMID: 33887756 PMCID: PMC8295867 DOI: 10.24875/acm.19000394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/07/2021] [Indexed: 11/17/2022] Open
Abstract
Today one of the main causes of mortality is cancer. Survival in cancer patients has increased from 1970 (25%) to the present (80%). Following the introduction of anthracyclines as a cancer treatment since 1960-70, more than 60% of patients are treated with these agents, although chemotherapeutic exposure leads to cardiovascular diseases as the main cause of mortality in surviving patients. of cancer in the 21st Century. There are multiple factors that increase the sensitivity of anthracyclic-induced cardiotoxicity. In 1970 the gold standard for the detection of ventricular dysfunction was endomyocardial biopsy, subsequently the detection and management of cardiotoxicity was guided by symptoms, in 1981 the detection of cardiotoxicity was reported with the determination of the ejection fraction of the left ventricle (LVEF), by 2D echocardiography. Currently, the 3D echocardiogram for LVEF and systolic and diastolic volumes have presented a high correlation of the values obtained by magnetic resonance imaging for the evaluation of cardiac function. Today strain, strain-rate and speckle tracking echocardiography are used to determine regional and global myocardial function. For a comprehensive assessment, these results can be complemented with cardiac biomarkers (troponins) and electrocardiographic changes. In this way, subclinical heart failure can be detected and timely treatment can be given.
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12
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Meiners B, Shenoy C, Zordoky BN. Clinical and preclinical evidence of sex-related differences in anthracycline-induced cardiotoxicity. Biol Sex Differ 2018; 9:38. [PMID: 30157941 PMCID: PMC6114275 DOI: 10.1186/s13293-018-0198-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/16/2018] [Indexed: 01/04/2023] Open
Abstract
Anthracyclines are very effective chemotherapeutic agents that are widely used to treat pediatric and adult cancer patients. Unfortunately, the clinical utility of anthracyclines is limited by cardiotoxicity. There are several established risk factors for anthracycline-induced cardiotoxicity (AIC), including total cumulative dose, very young and very old age, concomitant use of other cardiotoxic agents, and concurrent mediastinal radiation. However, the role of sex as a risk factor for AIC is not well defined. In pediatric cancer patients, most studies support the notion that female sex is a significant risk factor for AIC. Conversely, there is anecdotal evidence that female sex protects against AIC in adult cancer patients. The lack of consistency in study designs and the different definitions of cardiotoxicity preclude reaching consensus regarding the role of sex as a risk factor for AIC in both pediatric and adult cancer patients. Therefore, more clinical research using reliable techniques such as cardiac magnetic resonance imaging is needed to determine if there truly are sex differences in AIC. In adult preclinical rodent studies, however, there is unequivocal evidence that female sex confers significant protection against AIC, with a possible protective effect of female sex hormones and/or a detrimental role of the male sex hormones. Although findings of these rodent studies may not perfectly mirror the clinical scenario in adult anthracycline-treated cancer patients, understanding the mechanisms of this significant sexual dimorphism may reveal important cardioprotective mechanisms that can be therapeutically targeted.
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Affiliation(s)
- Becky Meiners
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 308 Harvard St S.E, Minneapolis, MN, 55455, USA
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Beshay N Zordoky
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 308 Harvard St S.E, Minneapolis, MN, 55455, USA.
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Abstract
Over the last 50 years, the survival rates in children with acute lymphoblastic leukemia (ALL) have increased remarkably. The optimal use of antileukemic agents in cooperative group protocols, central nervous system-directed treatment, improvements in supportive care, and recognition of biological, clinical, and treatment response characteristics that predict patients with a higher or a lower risk of treatment failure have improved 5-year event-free survival rates, reaching more than 85%, and 5-year overall survival rates, reaching more than 90%. Consequently, it has become increasingly important to characterize the occurrence of long-term late effects. ALL treatments have been associated with increased risks for adverse outcomes such as late mortality, secondary malignancies, and neurological, cardiac, endocrine, and social/psychological disorders. In recent decades, cooperative groups in Europe and in the United States have provided essential information about the long-term effects of ALL therapy, giving recommendations for screening as well as facilitating new approaches for reducing late-term morbidity and mortality. Current frontline protocols continue to examine ways to lower the intensity and amount of therapy to reduce late effects, whereas survivorship studies attempt to predict such adverse effects precisely and develop targeted prevention and treatment strategies.
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Affiliation(s)
- Hande Kızılocak
- Istanbul University-Cerrahpaşa Faculty of Medicine, Department of Pediatric Hematology and Oncology, İstanbul, Turkey
| | - Fatih Okcu
- Texas Children’s Hematology and Oncology Centers, Baylor College of Medicine, Department of Pediatrics, Division of Hematology and Oncology, Houston, TX, USA
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Schramm F, Zimmermann M, Jorch N, Pekrun A, Borkhardt A, Imschweiler T, Christiansen H, Faber J, Feuchtinger T, Schmid I, Beron G, Horstmann MA, Escherich G. Daunorubicin during delayed intensification decreases the incidence of infectious complications - a randomized comparison in trial CoALL 08-09. Leuk Lymphoma 2018; 60:60-68. [PMID: 29966458 DOI: 10.1080/10428194.2018.1473575] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Anthracyclines are integral components of antileukemic treatment. Apart from cardiotoxicity, myelosuppression and infectious complications have been described for doxorubicin (DOX) and daunorubicin (DNR) as predominant side effects, but little is known about their differential toxicities. To address the question whether DNR is associated with a lower rate of infectious complications compared with DOX, 307 children with newly diagnosed acute lymphoblastic leukemia, enrolled in trial CoALL 08-09, were randomized to receive either DOX 30 mg/m2 (n = 153) or DNR 36 mg/m2 (n = 154) in delayed intensification. Hematologic toxicities and stomatitis were less frequent in the DNR group resulting in a significantly lower rate of infections in the DNR arm (27% vs. 59%, p < .0001). Survival was equal in both arms (95% SE 2%) (p = .55), with an insignificant difference in the relapse rate (RR 0.12 (SE = 0.03) in the DOX arm vs. 0.16 (SE = 0.04) in the DNR arm; p = .37; Hazard ratio 1.3; 95% confidence interval 0.7-2.6). In conclusion, DNR given in delayed intensification is associated with a lower incidence of infectious complications without loss of efficacy.
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Affiliation(s)
- Franziska Schramm
- a Clinic of Pediatric Hematology and Oncology , University Medical Centre Hamburg-Eppendorf , Hamburg , Germany
| | - Martin Zimmermann
- k Research Institute Children's Cancer Centre , University Medical Centre Hamburg-Eppendorf , Hamburg , Germany
| | - Norbert Jorch
- b Department of Pediatric Hematology and Oncology , Medical School Hannover , Hannover , Germany
| | - Arnulf Pekrun
- c Department of Pediatric Hematology and Oncology , Hospital Bielefeld , Bielefeld , Germany
| | - Arndt Borkhardt
- d Department of Pediatric Hematology and Oncology , Hospital Bremen-Mitte , Bremen , Germany
| | - Thomas Imschweiler
- e Department of Pediatric Oncology, Hematology and Clinical Immunology , University Medical Centre , Düsseldorf , Germany
| | - Holger Christiansen
- f Department of Pediatric Hematology and Oncology , Helios Hospital , Krefeld , Germany
| | - Jörg Faber
- g Clinic of Pediatric Hematology and Oncology , University Medical Centre Leipzig , Leipzig , Germany
| | - Tobias Feuchtinger
- h Department of Pediatric Hematology/Oncology , University Hospital Mainz , Mainz , Germany
| | - Irene Schmid
- i Dr. von Hauner Children's Hospital , Ludwig Maximilians University , Munich , Germany
| | - Gerhard Beron
- g Clinic of Pediatric Hematology and Oncology , University Medical Centre Leipzig , Leipzig , Germany
| | - Martin A Horstmann
- a Clinic of Pediatric Hematology and Oncology , University Medical Centre Hamburg-Eppendorf , Hamburg , Germany.,j Department of Pediatric Hematology and Oncology , Helios Hospital , Wiesbaden , Germany
| | - Gabriele Escherich
- a Clinic of Pediatric Hematology and Oncology , University Medical Centre Hamburg-Eppendorf , Hamburg , Germany
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15
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Hung SH, Rankin A, Virji-Babul N, Pritchard S, Fryer C, Campbell KL. Associating Physical Activity Levels with Motor Performance and Physical Function in Childhood Survivors of Acute Lymphoblastic Leukemia. Physiother Can 2017; 69:57-64. [PMID: 28154445 DOI: 10.3138/ptc.2015-67lhc] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: This cross-sectional, observational study investigated whether physical activity (PA) levels are associated with motor performance and physical function in children after treatment for acute lymphoblastic leukemia (ALL). Method: Participants aged 8-13 years who had completed treatment for ALL (3-36 months post-treatment) were tested at their oncology long-term follow-up appointment at the British Columbia Children's Hospital. PA level was measured using the Physical Activity Questionnaire for Older Children (PAQ-C). Motor performance was measured using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, Short Form (BOT-2 SF), and physical function was measured using the 6-minute walk test (6MWT). Results: Thirteen children completed testing. PAQ-C scores were not associated with BOT-2 SF or 6MWT performance. Eleven children (85%) performed below the norm for the 6MWT. Children with elevated body mass index had poorer 6MWT but similar PAQ-C scores. Conclusion: PA was not found to be associated with motor performance and physical function. Participants who were overweight or obese had poorer 6MWT performance, which may indicate the need for closer monitoring of post-treatment weight status and physical function in the oncology follow-up setting.
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Affiliation(s)
- Stanley H Hung
- Department of Physical Therapy, University of British Columbia
| | - Anne Rankin
- Department of Physical Therapy, University of British Columbia
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16
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Järvelä LS, Saraste M, Niinikoski H, Hannukainen JC, Heinonen OJ, Lähteenmäki PM, Arola M, Kemppainen J. Home-Based Exercise Training Improves Left Ventricle Diastolic Function in Survivors of Childhood ALL: A Tissue Doppler and Velocity Vector Imaging Study. Pediatr Blood Cancer 2016; 63:1629-35. [PMID: 27198652 DOI: 10.1002/pbc.26051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 04/13/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Advanced echocardiographic methods may reveal signs of late anthracycline cardiac toxicity (ACT) even in asymptomatic patients. We studied echocardiographic tissue Doppler imaging (TDI) and velocity vector imaging (VVI) in long-term survivors of childhood acute lymphoblastic leukemia (ALL) before and after an exercise intervention. METHODS Twenty-one asymptomatic, anthracycline-treated, long-term childhood ALL survivors with matched controls were studied at baseline. Seventeen of the survivors participated in a 3-month home-based exercise program. Echocardiography with TDI and VVI was performed. RESULTS At baseline, ejection fraction (60.7 ± 4.7% vs. 62.3 ± 3.7%, P = 0.22) and fractional shortening (32.6 ± 3.1% vs. 34.0 ± 2.8%, P = 0.13) were similar in survivors and controls. Lateral early diastolic mitral annulus velocity E' (32.81 ± 5.71 cm/sec vs. 38.03 ± 6.21 cm/sec, P = 0.01), E'/A' (1.60 ± 0.48 vs. 2.07 ± 0.63, P = 0.01), and E/E' (2.78 ± 0.35 vs. 2.42 ± 0.62, P = 0.04) were impaired compared to controls. Peak circumferential strain and strain rate were attenuated at apex (-24.50 ± 3.46% vs. -28.06 ± 4.39%, P = 0.01 and -1.47 ± 0.22 sec(-1) vs. -1.68 ± 0.33 sec(-1) , P = 0.02) compared to controls. After the intervention, early diastolic mitral inflow velocity E (87.76 ± 12.54 cm/s vs. 95.28 ± 10.48 cm/s, P = 0.04) and E' increased (31.78 ± 5.50 cm/s vs. 34.96 ± 5.41 cm/s, P < 0.01). Peak circumferential systolic and diastolic strain rates at mid-level (-1.22 ± 0.21 sec(-1) vs. -1.35 ± 0.24 sec(-1) , P = 0.04 and 1.25 ± 0.25 sec(-1) vs. 1.48 ± 0.35 sec(-1) , P < 0.01) improved after the exercise program. CONCLUSIONS A simple home-based exercise program improved cardiac function in asymptomatic childhood ALL survivors. Adding TDI in routine echocardiographic examination may improve the recognition of early signs of ACT, and VVI may bring additional information. The improvements in cardiac function after the exercise program emphasize the importance of physical activity in this population.
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Affiliation(s)
- Liisa S Järvelä
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Markku Saraste
- Department of Clinical Physiology and Nuclear Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Harri Niinikoski
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland.,Institute of Biomedicine, University of Turku, Turku, Finland
| | | | - Olli J Heinonen
- Paavo Nurmi Centre, Department of Health and Physical activity, University of Turku, Turku, Finland
| | - Päivi M Lähteenmäki
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Mikko Arola
- Department of Paediatrics, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Jukka Kemppainen
- Department of Clinical Physiology and Nuclear Medicine, University of Turku and Turku University Hospital, Turku, Finland.,Turku PET Centre, University of Turku, Turku, Finland
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17
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Christiansen JR, Massey R, Dalen H, Kanellopoulos A, Hamre H, Fosså SD, Ruud E, Kiserud CE, Aakhus S. Utility of Global Longitudinal Strain by Echocardiography to Detect Left Ventricular Dysfunction in Long-Term Adult Survivors of Childhood Lymphoma and Acute Lymphoblastic Leukemia. Am J Cardiol 2016; 118:446-52. [PMID: 27296561 DOI: 10.1016/j.amjcard.2016.05.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
Abstract
Measuring left ventricular (LV) global longitudinal strain (GLS) is recommended in screening of long-term cancer survivors for cardiotoxicity. However, there are limited data on GLS in this setting, in particular in survivors with apparently normal LV function without risk factors of impaired GLS. In the present study, we measured GLS in 191 adult survivors of childhood lymphoma or acute lymphoblastic leukemia, with normal LV ejection fraction and fractional shortening (FS) and without known hypertension, diabetes mellitus, myocardial infarction, or stroke. We compared GLS in the survivors with 180 controls. Mean GLS was -19.0 ± 2.2% in the survivor group and -21.4 ± 2.0% in the controls (p <0.001). Impaired GLS, defined as mean - 1.96 SDs in the control group, occurred in 53 of 191 survivors (28%). We included survivors with impaired LV ejection fraction and/or FS or traditional risk factors (n = 231 in all) in multiple regression analyses to explore associations with previous cancer treatment. Survivors treated with mediastinal radiotherapy had an odds ratio of impaired GLS of 5.2 (95% confidence interval 2.2 to 12) compared with other survivors. Survivors treated with cumulative anthracycline doses >300 mg/m(2) had an odds ratio of 4.8 (95% confidence interval 1.7 to 14) of impaired GLS. In conclusion, this study demonstrates a high proportion of LV dysfunction assessed by GLS in apparently healthy adult survivors of childhood cancer. Impaired GLS was associated with previous exposure to mediastinal radiotherapy and high doses of anthracyclines. The prognostic role of measuring GLS in this specific patient population should be examined in prospective studies.
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18
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Toro-Salazar OH, Gillan E, Ferranti J, Orsey A, Rubin K, Upadhyay S, Mazur W, Hor KN. Effect of myocardial dysfunction in cardiac morbidity and all cause mortality in childhood cancer subjects treated with anthracycline therapy. CARDIO-ONCOLOGY 2015; 1:1. [PMID: 33530141 PMCID: PMC7837140 DOI: 10.1186/s40959-015-0005-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/29/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Subacute cardiotoxicity, consisting of acute myocyte damage and associated left ventricular dysfunction, occurs early during anthracycline therapy. We investigated the impact of myocardial dysfunction, defined herein by a shortening fraction (SF) < 29 % at any time during or after anthracycline therapy, on late onset cardiomyopathy and all-cause mortality, among childhood cancer survivors exposed to anthracyclines. In addition, we sought to identify subpopulations of subjects at highest risk for cardiomyopathy and death from all causes. METHODS Five hundred thirty-one childhood cancer survivors exposed to anthracyclines were enrolled and studied on average 10 (1.4-27.3) years following their initial exposure. The medical records were reviewed to identify known risk factors associated with cardiotoxicity, including cumulative anthracycline dose, length of post-therapy interval, administration of other cardiotoxic medications (vinca alkaloids), previous heart disease, radiation dose to the heart, history of bone marrow transplantation, age at treatment, gender, systolic dysfunction, and history of congestive heart failure during anthracycline therapy. RESULTS Ninety subjects (16.9 %) developed SF < 29 % and 71 patients (13.4 %) died on average 10 years after initial exposure (range 1.4-27.3 years). Total cumulative dose (OR 3.27, 95 % CI 1.94, 5.49, p < 0.001) and bone marrow transplantation (OR 2.57, 95 % CI 1.24, 5.30, p = 0.01) were found to be statistically significant risk factors for development of myocardial dysfunction. There was a 3-fold increase in the odds of having a SF < 29 % at any point during or following cancer therapy if a subject underwent bone marrow transplantation or had a total cumulative dose anthracycline therapy ≥ 240 mg/m2. The all-cause mortality ratio was almost seven-fold higher (95 % CI, 2.40-fold to 17.81-fold higher) if a subject developed systolic dysfunction, defined by a previous SF < 29 % anytime during or after anthracycline therapy. Nine deaths (12.7 %) were attributed to cardiovascular disease. The risk of dying as a result of cardiac disease also was significantly higher in individuals who had a SF < 29 % at any time during or after therapy. CONCLUSIONS This study demonstrates an almost seven-fold increase in all cause mortality in pediatric cancer survivors with a history of anthracycline induced myocardial dysfunction defined as SF < 29 %.
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Affiliation(s)
- Olga H Toro-Salazar
- Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
| | - Eileen Gillan
- Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA
| | - Joanna Ferranti
- Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA
| | - Andrea Orsey
- Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA
| | - Karen Rubin
- Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA
| | - Shailendra Upadhyay
- Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA
| | - Wojciech Mazur
- Ohio Heart and Vascular Center, The Christ Hospital, Cincinnati, OH, USA
| | - Kan N Hor
- Nationwide Children's Hospital, Columbus, OH, USA
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19
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Christiansen JR, Kanellopoulos A, Lund MB, Massey R, Dalen H, Kiserud CE, Ruud E, Aakhus S. Impaired exercise capacity and left ventricular function in long-term adult survivors of childhood acute lymphoblastic leukemia. Pediatr Blood Cancer 2015; 62:1437-43. [PMID: 25832752 DOI: 10.1002/pbc.25492] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/03/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for late cardiotoxic effects of cancer treatment, but conflicting evidence exists on the effects of anthracyclines on left ventricular (LV) diastolic function and exercise capacity. PROCEDURE We performed a cross-sectional study with comprehensive echocardiography in 138 adult survivors of childhood ALL, median 23.4 years after diagnosis. Pulsed tissue Doppler measurements of early diastolic mitral annular velocities (e') were used for the assessment of diastolic function, and compared to 138 matched controls. Of the survivors, 133 also performed ergospirometry measuring peak oxygen uptake (VO2 max). Associations between cancer treatment, LV function, and VO2 max were analyzed. RESULTS The survivor group had lower e' values than controls (e' septal 11.0 vs. 12.6 cm/s, P < 0.001), but the difference was confined to the subgroup of anthracycline treated survivors (median cumulative dose 120 mg/m(2) ). Anthracycline exposure was inversely correlated with e' (regression coefficient -1.581, P=0.009). Reduced VO2 max/kg occurred in 47% of the survivors, but more often in anthracycline treated survivors (56%) than anthracycline naïve survivors (17%, P<0.001). Anthracycline exposure was inversely correlated with VO2 max/kg (regression coefficient -3.084, P = 0.05 in multivariate analysis). Furthermore, associations were observed between measures of LV function and VO2 max/kg, and e' was the best predictor of VO2 max/kg (standardized coefficient 0.355, P < 0.001 in multivariate analysis). CONCLUSIONS Adult survivors of childhood ALL have increased risk for impaired LV diastolic function and impaired exercise capacity, both associated with previous anthracycline exposure. Furthermore, there is an association between LV diastolic function and exercise capacity.
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Affiliation(s)
- Jon R Christiansen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Department of Medicine, Innlandet Hospital Trust, Elverum, Norway
| | - Adriani Kanellopoulos
- Department of Pediatric Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - May B Lund
- Department of Respiratory Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Richard Massey
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Håvard Dalen
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cecilie E Kiserud
- National Resource Centre for Late Effects after Cancer Treatment, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Ellen Ruud
- Department of Pediatric Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Svend Aakhus
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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20
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Bayram C, Çetin İ, Tavil B, Yarali N, Ekici F, Isık P, Tunc B. Evaluation of cardiotoxicity by tissue Doppler imaging in childhood leukemia survivors treated with low-dose anthracycline. Pediatr Cardiol 2015; 36:862-6. [PMID: 25577226 DOI: 10.1007/s00246-015-1096-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 01/07/2015] [Indexed: 01/04/2023]
Abstract
Improvement in long-term survival in patients with acute childhood leukemia has led to the need for monitorization of chemotherapy-related morbidity and mortality. This study included 60 patients with acute lymphoblastic leukemia that were in remission for at least 2 years and 30 healthy controls. Systolic and diastolic function of myocardium was evaluated using conventional echocardiography and tissue Doppler imaging of the left ventricle, interventricular septum and right ventricle. Median age of patients was 11.7 years (range 10-14.9 years), and the median duration of remission was 4 years (range 2.5-5 years). All patients were treated with a low cumulative dose of adriamycin (100 mg/m(2)) according to the St. Jude Total-XIIIA protocol. The ejection fraction (EF) and fractional shortening were normal in the patient and control groups, even though EF values were significantly lower in the patients (69.5 ± 2.3 vs. 72.7 ± 3 %, P < 0.01). Myocardial systole (S m), early diastole (E m) and late diastole (A m) velocities in all segments of the myocardium were significantly lower in the patient group (P < 0.01 for all segments). Cardiotoxicity was noted in all segments of the myocardium in the patient group, despite the fact that they were all treated with a low cumulative dose of adriamycin. Based on these findings, we think that there is no safe dose for anthracyclines and periodic echocardiographic evaluation of both the left and right ventricles must be performed in all patients treated with anthracyclines, even at low doses.
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Affiliation(s)
- Cengiz Bayram
- Department of Pediatric Hematology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey,
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21
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Armenian SH, Hudson MM, Mulder RL, Chen MH, Constine LS, Dwyer M, Nathan PC, Tissing WJE, Shankar S, Sieswerda E, Skinner R, Steinberger J, van Dalen EC, van der Pal H, Wallace WH, Levitt G, Kremer LCM. Recommendations for cardiomyopathy surveillance for survivors of childhood cancer: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2015; 16:e123-36. [PMID: 25752563 PMCID: PMC4485458 DOI: 10.1016/s1470-2045(14)70409-7] [Citation(s) in RCA: 375] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Survivors of childhood cancer treated with anthracycline chemotherapy or chest radiation are at an increased risk of developing congestive heart failure. In this population, congestive heart failure is well recognised as a progressive disorder, with a variable period of asymptomatic cardiomyopathy that precedes signs and symptoms. As a result, several clinical practice guidelines have been developed independently to help with detection and treatment of asymptomatic cardiomyopathy. These guidelines differ with regards to definitions of at-risk populations, surveillance modality and frequency, and recommendations for interventions. Differences between these guidelines could hinder the effective implementation of these recommendations. We report on the results of an international collaboration to harmonise existing cardiomyopathy surveillance recommendations using an evidence-based approach that relied on standardised definitions for outcomes of interest and transparent presentation of the quality of the evidence. The resultant recommendations were graded according to the quality of the evidence and the potential benefit gained from early detection and intervention.
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Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, USA.
| | - Melissa M Hudson
- Departments of Oncology and Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Renee L Mulder
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Ming Hui Chen
- Department of Pediatrics, Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Mary Dwyer
- Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Paul C Nathan
- The Hospital for Sick Children and the University of Toronto, Department of Pediatrics and Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - Wim J E Tissing
- Division of Pediatric Oncology and Pediatric Hematology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sadhna Shankar
- Division of Oncology, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA
| | - Elske Sieswerda
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Rod Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital and University of Newcastle, Newcastle upon Tyne, UK
| | - Julia Steinberger
- Department of Pediatrics, Division of Cardiology, University of Minnesota Amplatz Childrens' Hospital, Minneapolis, MN, USA
| | - Elvira C van Dalen
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Helena van der Pal
- Department of Pediatric Oncology and Medical Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - W Hamish Wallace
- Department of Hematology/Oncology, Royal Hospital for Sick Children, Edinburgh, Scotland
| | - Gill Levitt
- Department of Oncology/Haematology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Leontien C M Kremer
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
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Sadurska E. Current Views on Anthracycline Cardiotoxicity in Childhood Cancer Survivors. Pediatr Cardiol 2015; 36:1112-9. [PMID: 25939787 PMCID: PMC4495714 DOI: 10.1007/s00246-015-1176-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/18/2015] [Indexed: 12/28/2022]
Abstract
Owing to their high efficacy, anthracycline antibiotics are included in numerous chemotherapeutic regimens used-often in combination with radiation therapy and/or surgery-in treatment of solid tumours and blood malignancies, both in children and adults. However, the efficacy of modern cancer treatments, owing to which the population of cancer survivors has been on the rise in recent years, may be limited by the risk of serious complications involving multiple organs and systems, including the cardiovascular system. Being an important side effect of anthracyclines, cardiotoxicity may limit the efficacy of cancer therapies in the acute phase (i.e. during the treatment) and induce the long-term sequelae, observed years after treatment completion in childhood cancer survivors. It is very important to understand the cardiotoxicity-associated mechanisms and to determine its risk factors in order to develop and/or improve the effective countermeasures. Based on published data, the paper provides an outline of current views on anthracycline cardiotoxicity and discusses such aspects as molecular mechanisms of cardiotoxicity and its clinical manifestations as well as the new preventive strategies and diagnostic techniques used for the assessment of cardiovascular abnormalities. The widespread awareness of cancer treatment-related cardiotoxicity among the healthcare professionals may significantly improve the quality of life of the childhood cancer survivors.
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Affiliation(s)
- Elżbieta Sadurska
- Department of Pediatric Cardiology, Medical University of Lublin, Chodźki 2, 20-093, Lublin, Poland,
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23
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Left ventricular function in long-term survivors of childhood lymphoma. Am J Cardiol 2014; 114:483-90. [PMID: 24948492 DOI: 10.1016/j.amjcard.2014.04.055] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 11/23/2022]
Abstract
Survivors of childhood lymphoma (CL) have markedly increased risk of developing heart failure. Echocardiographic studies after cardiotoxic treatment have primarily demonstrated left ventricular (LV) systolic dysfunction. In the present study, we hypothesized that longer follow-up and a more comprehensive echocardiographic examination would reveal more cardiac abnormalities. We conducted a cross-sectional study with echocardiography 20.4 ± 8.6 years after diagnosis in 125 survivors of CL, grouped according to treatment methods, and compared with matched controls. Treatment included mediastinal radiotherapy (median 40.0 Gy) in 66 and anthracyclines (median dose 160 mg/m(2)) in 92 survivors of CL. Abnormal LV function, left-sided valve dysfunction, or both occurred in 62 patients (50%). Diastolic dysfunction occurred in 29%. Compared with control subjects, mitral annular early diastolic velocities (e') were reduced in patients (septal e' 0.09 ± 0.03 vs 0.12 ± 0.03 m/s, p <0.001), and the E/e' ratio was increased, particularly after mediastinal radiotherapy (10.6 ± 6.4 vs 5.6 ± 1.3, p <0.001). Survivors of CL had lower fractional shortening than control subjects (32 ± 6 vs 36 ± 7, p <0.001), but mean ejection fraction was equal and overt systolic dysfunction was infrequent. After mediastinal radiotherapy alone, global longitudinal myocardial strain was lower (p <0.05) compared with other treatment groups. Left-sided valvular dysfunction occurred in 55% of patients after mediastinal radiotherapy. In conclusion, survivors of CL had reduced LV diastolic function assessed by tissue Doppler imaging. This was more pronounced after mediastinal radiotherapy, which also frequently led to valvular disease. Systolic function was normal in most survivors of CL.
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Ma Y, Kang W, Bao Y, Jiao F, Ma Y. Clinical significance of ischemia-modified albumin in the diagnosis of doxorubicin-induced myocardial injury in breast cancer patients. PLoS One 2013; 8:e79426. [PMID: 24223946 PMCID: PMC3817059 DOI: 10.1371/journal.pone.0079426] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 09/23/2013] [Indexed: 01/22/2023] Open
Abstract
Background Ischemia-modified albumin is an altered serum albumin that forms under conditions of oxidative stress, a state also associated with doxorubicin-induced myocardial injury. Objective The aim of this study was to better assess diagnostic and prognostic significance of ischemia-modified albumin in patients with breast cancer undergoing doxorubicin chemotherapy. Methods Blood samples were collected from 152 breast cancer patients before and after each cycle of doxorubicin chemotherapy to measure the serum levels of ischemia-modified albumin, cardiac troponin T and creatine kinase-MB. We also monitored cardiac function during a 12 month follow-up. Results There was a significant difference in ischemia-modified albumin levels before and after each cycle of chemotherapy and the ischemia-modified albumin concentration positively correlated with the cumulative dose of doxorubicin (r = 0.212, P < 0.05). The combination of ischemia-modified albumin with cardiac troponin T and creatine kinase-MB increased the sensitivity to 0.920 and the specificity to 0.830 in the diagnosis of doxorubicin-induced myocardial injury. The optimal cutoff for ischemia-modified albumin concentration was 112.09 U/ml. The rate of change for ischemia-modified albumin levels correlated negatively with the rate of change for left ventricular ejection fraction at one year (r = –0.221, P < 0.05). Conclusion Ischemia-modified albumin may be a clinically potential new marker for diagnosing doxorubicin-induced myocardial injury, and is helpful to predict long-term impairment of cardiac function.
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Affiliation(s)
- Yinghuan Ma
- Department of Cancer, The 463rd Hospital of the Chinese PLA, Shenyang, Liaoning, People’s Republic of China
| | - Wanjun Kang
- Department of Cancer, The 463rd Hospital of the Chinese PLA, Shenyang, Liaoning, People’s Republic of China
| | - Yongxin Bao
- Department of Cancer, The 463rd Hospital of the Chinese PLA, Shenyang, Liaoning, People’s Republic of China
| | - Fubin Jiao
- Division of Health, Bureau of Guard, General Advisor Office of Chinese PLA, Beijing, People’s Republic of China
| | - Yiran Ma
- Department of Transfusion, The First Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
- * E-mail:
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Educational paper: decreasing the burden of cardiovascular disease in childhood cancer survivors: an update for the pediatrician. Eur J Pediatr 2013; 172:1149-60. [PMID: 23361962 DOI: 10.1007/s00431-013-1931-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 01/08/2013] [Indexed: 12/31/2022]
Abstract
The cardiovascular impact of cancer therapies on the heart is one of the major concerns in the long-term follow-up of childhood cancer survivors (CCSs). Long-term cardiovascular effects include the development of left ventricular dysfunction resulting in congestive heart failure and ischemic heart disease, as well as valvular and pericardial disease. This is mainly ascribed to the cardiotoxic side effects of chemotherapeutic agents (especially anthracyclines) and radiotherapy, but other factors such as radiation and inflammation play a role in the effect of childhood cancer on the cardiovascular health. The most concerning effect is the high incidence of symptomatic heart failure in CCS patients treated with anthracyclines. More than 50 % of CCSs treated with anthracyclines develop asymptomatic left ventricular dysfunction after cancer therapy, with approximately 5 % developing clinical signs of heart failure during long-term follow-up. Once CCS patients develop congestive heart failure, prognosis is poor and is not influenced by current medical treatment strategies. To reduce the long-term burden of cardiovascular disease in pediatric cancer patients, a diversified approach will be necessary. In the acute phase, prevention of cardiac damage through the use of cardioprotective agents (e.g., dexrazoxane) or by administering less cardiotoxic chemotherapeutic agents is to be considered. A recent randomized trial suggested that the use of dexrazoxane reduced cardiac toxicity without affecting cancer outcomes. Especially patients requiring high doses of chemotherapeutic agents could benefit from this approach. Recent data suggest that genetic testing might identify patients at higher risk for cardiotoxicity. This seems mainly related to genes involved in drug metabolism. This would allow personalized approach adjusting chemotherapy based on cardiovascular risk profiling. This could be combined with newer monitoring strategies in the acute phase using newer echocardiographic techniques and biomarker screening to identify patients with early damage to the myocardium. For the long-term CCS cohort, early detection and treatment of early dysfunction prior to the development of congestive heart failure could potentially improve long-term outcomes. Promoting healthy lifestyles and controlling additional cardiovascular risk factors (e.g., obesity, diabetes, arterial hypertension) is an important task for every physician involved in the care of this growing cohort.
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de Ville de Goyet M, Moniotte S, Brichard B. Cardiotoxicity of childhood cancer treatment: update and current knowledge on long-term follow-up. Pediatr Hematol Oncol 2012; 29:395-414. [PMID: 22732022 DOI: 10.3109/08880018.2012.694092] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Therapeutic advances in paediatric oncology allowed increasing numbers of children to survive until adulthood. However, chemotherapy and radiotherapy are potentially cardiotoxic and contribute to a significant morbidity and mortality, cardiovascular events remaining the leading cause of death among survivors. This review summarizes the physiopathology of treatment-related cardiovascular diseases, their incidence, and the risk factors associated with each specific therapy. Few studies have investigated the cardiac outcomes of adult surviving from childhood cancers but all demonstrated a substantial risk for late cardiac effects. Cardiovascular monitoring, prevention, and early detection of cardiac dysfunction are, therefore, the keystones of an improved long-term outcome.
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Affiliation(s)
- Maëlle de Ville de Goyet
- Department of Paediatric Haematology and Oncology, Cliniques universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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27
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Hayward R, Lien CY, Jensen BT, Hydock DS, Schneider CM. Exercise training mitigates anthracycline-induced chronic cardiotoxicity in a juvenile rat model. Pediatr Blood Cancer 2012; 59:149-54. [PMID: 22052855 DOI: 10.1002/pbc.23392] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 09/20/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Childhood cancer survivors are at greater risk of cardiovascular complications once they reach adulthood. Anthracyclines may be a major contributor to these delayed-onset complications, yet their use continues because of favorable clinical outcomes. Exercise has been shown to protect against anthracycline cardiotoxicity, yet it is unclear whether exercise can protect against delayed-onset cardiotoxicity when treatment is initiated in childhood. The aim of the present study was to determine if exercise training provides cardioprotection in a juvenile rat model of delayed-onset anthracycline cardiotoxicity. PROCEDURE At 25 days of age, male Sprague-Dawley rat pups were subjected to a treatment regimen with the anthracycline doxorubicin (DOX). Pups received DOX at 2 mg/kg on 7 consecutive days (cumulative dose 14 mg/kg) or saline as a control. At the time DOX treatment began, pups remained sedentary or were allowed to voluntarily exercise. Ten weeks after the initiation of exercise, cardiac function was assessed both in vivo and ex vivo. RESULTS DOX treatment stunted normal growth and significantly impaired cardiac function. While voluntary exercise did not offset changes in the growth curve, it did provide significant cardioprotection against DOX-induced cardiotoxicity. CONCLUSIONS Exercise training, initiated at the time treatment begins, can protect against delayed-onset anthracycline-induced cardiotoxicity in adult rats that were treated with anthracyclines as juveniles.
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Affiliation(s)
- Reid Hayward
- School of Sport and Exercise Science and the Rocky Mountain Cancer Rehabilitation Institute, University of Northern Colorado, Greeley, Colorado 80639, USA.
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28
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The mutations associated with dilated cardiomyopathy. Biochem Res Int 2012; 2012:639250. [PMID: 22830024 PMCID: PMC3399391 DOI: 10.1155/2012/639250] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Revised: 04/25/2012] [Accepted: 05/17/2012] [Indexed: 01/18/2023] Open
Abstract
Cardiomyopathy is an important cause of heart failure and a major indication for heart transplantation in children and adults. This paper describes the state of the genetic knowledge of dilated cardiomyopathy (DCM). The identification of the causing mutation is important since presymptomatic interventions of DCM have proven value in preventing morbidity and mortality. Additionally, as in general in genetic studies, the identification of the mutated genes has a direct clinical impact for the families and population involved. Identifying causative mutations immediately amplifies the possibilities for disease prevention through carrier screening and prenatal testing. This often lifts a burden of social isolation from affected families, since healthy family members can be assured of having healthy children. Identification of the mutated genes holds the potential to lead to the understanding of disease etiology, pathophysiology, and therefore potential therapy. This paper presents the genetic variations, or disease-causing mutations, contributing to the pathogenesis of hereditary DCM, and tries to relate these to the functions of the mutated genes.
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30
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Watts RG, George M, Johnson WH. Pretreatment and routine echocardiogram monitoring during chemotherapy for anthracycline-induced cardiotoxicity rarely identifies significant cardiac dysfunction or alters treatment decisions: a 5-year review at a single pediatric oncology center. Cancer 2011; 118:1919-24. [PMID: 21882180 DOI: 10.1002/cncr.26481] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 07/05/2011] [Accepted: 07/06/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND The widespread use of anthracycline chemotherapy has contributed to improved outcomes in children with cancer. The most feared complication of the anthracyclines is cardiotoxicity. Routine echocardiographic monitoring typically is used before, during, and after treatment to minimize cardiotoxicity. The ideal use of screening before and during chemotherapy remains uncertain. METHODS This was a retrospective review of children who were treated at a single cancer treatment center over 5 years. The results of all echocardiograms and related clinical decisions were reviewed. RESULTS In 356 patients who were identified for review (age range, 3 months to 22 years; mean age, 10 years; median age, 11 years), 991 echocardiograms were reviewed (average, 2.78 echocardiograms per patient; median, 2 echocardiograms per patient; mode, 1; maximum, 11 echocardiograms per patient). Nine abnormal echocardiograms were identified (2.5% of patients and 0.9% of echocardiograms performed). Four echocardiograms were performed during episodes of septic shock, 2 echocardiograms represented false-positive studies after repeat evaluation, and 1 echocardiogram demonstrated mild abnormality of function on the day of surgical resection of a large Wilms tumor. None of the 356 pretreatment echocardiograms altered treatment decisions. In 635 follow-up echocardiograms during treatment, cardiac defects were detected in 2 patients (0.5%). CONCLUSIONS The routine use of echocardiograms to screen for anthracycline-induced cardiac damage before and during chemotherapy rarely identified significant cardiac damage to impact treatment decisions. Improved screening techniques with better discrimination and predictability are needed. Pediatric Oncology cooperative groups should consider a revision of standard monitoring protocols before and during treatment.
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Affiliation(s)
- Raymond G Watts
- Division of Hematology-Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama 35233, USA.
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31
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Fulbright JM, Raman S, McClellan WS, August KJ. Late Effects of Childhood Leukemia Therapy. Curr Hematol Malig Rep 2011; 6:195-205. [DOI: 10.1007/s11899-011-0094-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bibliography. Obstetric and gynaecological anesthesia. Current world literature. Curr Opin Anaesthesiol 2011; 24:354-6. [PMID: 21637164 DOI: 10.1097/aco.0b013e328347b491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fulbright JM. Review of cardiotoxicity in pediatric cancer patients: during and after therapy. Cardiol Res Pract 2011; 2011:942090. [PMID: 21637324 PMCID: PMC3102324 DOI: 10.4061/2011/942090] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 01/31/2011] [Accepted: 03/17/2011] [Indexed: 01/12/2023] Open
Abstract
With the improvement in survival from childhood cancer, late effects of therapy are becoming more apparent. Cardiac disease, one of these late effects, has a significant impact on the life of survivors of childhood cancers. Most survivors are followed by primary care doctors and adult subspecialists after they have graduated from pediatric centers. Since much of the cardiac toxicity of therapy occurs years off of therapy, it is important for these physicians to be aware of how to monitor survivors for the development of cardiac toxicities. In this paper we will discuss the incidence of cardiac disease during treatment and in survivors, what treatment modalities contribute to its development and modalities utilized to screen for cardiac disease. Recommendations for posttherapy monitoring will be emphasized.
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Affiliation(s)
- Joy M. Fulbright
- Division of Pediatric Hematology/Oncology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
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35
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Ness KK, Armenian SH, Kadan-Lottick N, Gurney JG. Adverse effects of treatment in childhood acute lymphoblastic leukemia: general overview and implications for long-term cardiac health. Expert Rev Hematol 2011; 4:185-97. [PMID: 21495928 PMCID: PMC3125981 DOI: 10.1586/ehm.11.8] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Survival of childhood acute lymphoblastic leukemia (ALL) is one of the greatest medical success stories of the last four decades. Unfortunately, childhood ALL survivors experience medical late effects that increase their risk of morbidity and premature death, often due to heart and vascular disease. Research has helped elucidate the mechanisms and trajectory of direct damage to the heart from treatment exposure, particularly to anthracyclines, and has also contributed knowledge on the influences of related chronic conditions, such as obesity and insulin resistance on heart health in these survivors. This article summarizes the key issues associated with early morbidity and mortality from cardiac-related disease in childhood ALL survivors and suggests directions for interventions to improve long-term outcomes.
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Affiliation(s)
- Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Mail Stop 735, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Saro H Armenian
- Outcomes Research, Population Sciences, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010-3000, USA
| | - Nina Kadan-Lottick
- Section of Pediatric Hematology–Oncology, Yale University School of Medicine, 333 Cedar Street, LMP-2073, New Haven, CT 06520-8064, USA
| | - James G Gurney
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Mail Stop 735, 262 Danny Thomas Place, Memphis, TN 38105, USA
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Sepe DM, Ginsberg JP, Balis FM. Dexrazoxane as a cardioprotectant in children receiving anthracyclines. Oncologist 2010; 15:1220-6. [PMID: 21051660 DOI: 10.1634/theoncologist.2010-0162] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Anthracyclines play a critical role in the treatment of a variety of childhood cancers. However, the cumulative cardiotoxic effects of anthracyclines limit the use of these agents in many treatment regimens. Dexrazoxane is a cardioprotectant that significantly reduces the incidence of adverse cardiac events in women with advanced breast cancer treated with doxorubicin-containing regimens. Clinical evidence for the efficacy of dexrazoxane as a cardioprotectant in children, especially from randomized clinical trials, is limited, but the available data support a short-term cardioprotective effect. Long-term follow-up in children treated with dexrazoxane has not been reported. Dexrazoxane's impact on the antitumor effect and toxicity profile of the anthracyclines and the role of dexrazoxane in the development of secondary malignant neoplasms in patients who received dexrazoxane are reviewed. Based on the available data, dexrazoxane appears to be a safe and effective cardioprotectant in children, and it does not appear to alter overall survival times in children with cancer. Continued follow-up from previous trials is needed to determine the long-term effect of dexrazoxane on cardiac outcomes and quality of life.
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Affiliation(s)
- Dana M Sepe
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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