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Masood IR, Rezvan PH, Lee K, Vervaet H, Kuo C, Loss K, Menteer J, Souza A, Freyer D, Su JA. Left Ventricle Size Correlates with Peak Exercise Capacity in Pediatric Cancer Survivors Exposed to Anthracycline Chemotherapy. Pediatr Cardiol 2024; 45:1493-1502. [PMID: 37217803 PMCID: PMC10202348 DOI: 10.1007/s00246-023-03192-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023]
Abstract
Cancer survivors exposed to anthracycline chemotherapy are at risk for developing cardiomyopathy, which may have delayed clinical manifestation. In a retrospective cross-sectional study, we evaluated the utility of cardiopulmonary exercise testing (CPET) for detecting early cardiac disease in 35 pediatric cancer survivors by examining the associations between peak exercise capacity (measured via percent predicted peak VO2) and resting left ventricular (LV) function on echocardiography and cardiac magnetic resonance imaging (cMRI). We additionally assessed the relationships between LV size on resting echocardiography or cMRI and percent predicted peak VO2 since LV growth arrest can occur in anthracycline-exposed patients prior to changes in LV systolic function. We found reduced exercise capacity in this cohort, with low percent predicted peak VO2 (62%, IQR: 53-75%). While most patients in our pediatric cohort had normal LV systolic function, we observed associations between percent predicted peak VO2 and echocardiographic and cMRI measures of LV size. These findings indicate that CPET may be more sensitive in manifesting early anthracycline-induced cardiomyopathy than echocardiography in pediatric cancer survivors. Our study also highlights the importance of assessing LV size in addition to function in pediatric cancer survivors exposed to anthracyclines.
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Affiliation(s)
- Imran Ross Masood
- Heart Institute, Children’s Hospital of Los Angeles, Los Angeles, USA
| | - Panteha Hayati Rezvan
- Biostatistics and Data Analysis Core, The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, USA
| | - Kyuwan Lee
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA USA
| | - Helena Vervaet
- Present Address: Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Christopher Kuo
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, USA
| | - Karla Loss
- Heart Institute, Children’s Hospital of Los Angeles, Los Angeles, USA
| | - JonDavid Menteer
- Heart Institute, Children’s Hospital of Los Angeles, Los Angeles, USA
| | - Andrew Souza
- Heart Institute, Children’s Hospital of Los Angeles, Los Angeles, USA
| | - David Freyer
- Present Address: Keck School of Medicine, University of Southern California, Los Angeles, USA
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, USA
| | - Jennifer A. Su
- Heart Institute, Children’s Hospital of Los Angeles, Los Angeles, USA
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2
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Gándara-Mireles JA, Lares-Asseff I, Reyes Espinoza EA, Córdova Hurtado LP, Payan Gándara H, Botello Ortiz M, Loera Castañeda V, Patrón Romero L, Almanza Reyes H. Nutritional Status as a Risk Factor for Doxorubicin Cardiotoxicity in Mexican Children with Acute Lymphoblastic Leukemia. Nutr Cancer 2024; 76:952-962. [PMID: 38994569 DOI: 10.1080/01635581.2024.2378502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 07/13/2024]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common childhood cancer in the world. Doxorubicin (Dox) is a very useful drug in these patients, however, one of the main adverse effects caused by the use of Dox is cardiotoxicity (CT). Protein-calorie malnutrition (PCM) is a factor that, among others, can influence the development of CT due to Dox. The aim of our study was to associate PCM as a risk factor for CT induced by Dox in Mexican children with ALL. We included 89 children with ALL who were treated with Dox, from October 2018 to July 2023, and of whom 14 developed some type of CT, 15 were underweight and 3 were overweight. The analysis of the association risk of CT due to PCM shows a statistically significant association of risk of developing CT due to PCM. On the other hand, healthy weight was associated with protection for developing CT due to Dox use. Of the total number of girls who presented CT, all had systolic dysfunction, while 6 of them also had diastolic dysfunction. On the other hand, of the total number of boys who presented CT, all of them had systolic dysfunction and only one of them also had diastolic dysfunction. These results show that in patients in which Dox is being administered, special attention is suggested for girls with PCM, since systolic failure is a precursor and occurs before diastolic failure in girls with PCM.
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Affiliation(s)
- Jesús Alonso Gándara-Mireles
- Academia de Genómica, Instituto Politécnico Nacional, CIIDIR-Unidad Durango, México
- Red Latinoamericana de Implementación y Validación de Guías Clínicas Farmacogenómicas (RELIVAF-CYTED)
| | - Ismael Lares-Asseff
- Academia de Genómica, Instituto Politécnico Nacional, CIIDIR-Unidad Durango, México
- Red Latinoamericana de Implementación y Validación de Guías Clínicas Farmacogenómicas (RELIVAF-CYTED)
| | | | | | - Hugo Payan Gándara
- Servicio de Hemato-Oncología Pediátrica, Centro Estatal de Cancerología, CECAN Durango, México
| | | | - Verónica Loera Castañeda
- Academia de Genómica, Instituto Politécnico Nacional, CIIDIR-Unidad Durango, México
- Red Latinoamericana de Implementación y Validación de Guías Clínicas Farmacogenómicas (RELIVAF-CYTED)
| | - Leslie Patrón Romero
- Facultad de Medicina y Psicología, Universidad Autónoma de Baja California, Tijuana, México
| | - Horacio Almanza Reyes
- Red Latinoamericana de Implementación y Validación de Guías Clínicas Farmacogenómicas (RELIVAF-CYTED)
- Facultad de Medicina y Psicología, Universidad Autónoma de Baja California, Tijuana, México
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Norton N, Weil RM, Advani PP. Inter-Individual Variation and Cardioprotection in Anthracycline-Induced Heart Failure. J Clin Med 2021; 10:jcm10184079. [PMID: 34575190 PMCID: PMC8465671 DOI: 10.3390/jcm10184079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 12/20/2022] Open
Abstract
Anthracyclines are one of the most widely used and effective chemotherapies in oncology, but their most important side effect is the cumulative, dose-related cardiotoxicity leading to congestive heart failure in ~5% of individuals. Methodology and pharmacogenetic studies for predicting which individuals are at high risk and subsequently the development of targeted and individualized cardioprotective plans are beginning to make progress. Here, we review current putative risk genes and variants, the strength of evidence for each genetic association and the interaction between risk genes, in the context of known clinical risk factors and potential novel cardioprotective strategies.
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Affiliation(s)
- Nadine Norton
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA;
- Correspondence: ; Tel.: +1-(904)-953-6352
| | - Raegan M. Weil
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Pooja P. Advani
- Department of Hematology and Oncology, Mayo Clinic, Jacksonville, FL 32224, USA;
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A compound combination screening approach with potential to identify new treatment options for paediatric acute myeloid leukaemia. Sci Rep 2020; 10:18514. [PMID: 33116257 PMCID: PMC7595190 DOI: 10.1038/s41598-020-75453-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/15/2020] [Indexed: 02/06/2023] Open
Abstract
Paediatric acute myeloid leukaemia (AML) is a heterogeneous disease characterised by genetics and morphology. The introduction of intensive chemotherapy treatments together with patient stratification and supportive therapy has resulted in a moderate improvement in patient prognosis. However, overall survival rates remain unacceptably poor, with only 65% of patients surviving longer than 5 years. Recently age-specific differences in AML have been identified, highlighting the need for tailored treatments for paediatric patients. Combination therapies have the potential to improve patient prognosis, while minimising harmful side-effects. In the laboratory setting, identifying key combinations from large drug libraries can be resource-intensive, prohibiting discovery and translation into the clinic. To minimise redundancy and maximise discovery, we undertook a multiplex screen of 80 apoptotic-inducing agents in paediatric AML pre-clinical models. The screen was designed using an all-pairs testing algorithm, which ensured that all pairs of compounds could be tested, while minimising the number of wells used. We identified a combination of ABT-737, a Bcl-2 family inhibitor and Purvalanol A, a CDK inhibitor, as a potential targeted therapy for AML patients with an MLL rearrangement and an FLT3-ITD. Our approach has the potential to reduce resource-intensity and time associated with the identification of novel combination therapies.
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Cooper TM, Absalon MJ, Alonzo TA, Gerbing RB, Leger KJ, Hirsch BA, Pollard J, Razzouk BI, Aplenc R, Kolb EA. Phase I/II Study of CPX-351 Followed by Fludarabine, Cytarabine, and Granulocyte-Colony Stimulating Factor for Children With Relapsed Acute Myeloid Leukemia: A Report From the Children's Oncology Group. J Clin Oncol 2020; 38:2170-2177. [PMID: 32401633 DOI: 10.1200/jco.19.03306] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Effective regimens are needed for children with relapsed acute myeloid leukemia (AML). AAML1421 is a phase I/II study of CPX-351, a liposomal preparation of daunorubicin and cytarabine. AAML1421 sought to determine the recommended phase II dose (RP2D) of CPX-351 and the response rate after up to 2 cycles of therapy. PATIENTS AND METHODS Children > 1 and ≤ 21 years of age with relapsed/refractory AML were eligible for dose finding; those in first relapse were eligible for the efficacy phase. Dose-limiting toxicity (DLT) assessment occurred during cycle 1. Two cycles of therapy were offered (cycle 1: CPX-351; cycle 2: FLAG [fludarabine 30 mg/m2/dose on days 1-5; cytarabine 2,000 mg/m2/dose on days 1-5; and granulocyte-colony stimulating factor 5 µg/kg/dose, days 1-5 and day 15 through absolute neutrophil count > 500/µL]). Response was assessed after each cycle. RESULTS Thirty-eight patients enrolled: 6 in the dose-finding phase and 32 in the efficacy phase. During dose finding, 1/6 patients experienced a DLT (grade 3 decrease in ejection fraction). The RP2D was 135 units/m2 on days 1, 3, and 5. Toxicities of grade ≥ 3 during cycle 1 included fever/neutropenia (45%), infection (47%), and rash (40%). There was no toxic mortality. Best responses included 20 complete response (CR; 54%), 5 CR with partial recovery of platelet count (CRp; 14%), and 5 CR with incomplete blood count recovery (14%). Twenty-one of 25 with CR/CRp had no detectable residual disease (RD; 84%) by flow cytometry. Hematopoietic stem cell transplantation (HSCT) was used as consolidation in 29/30 responders (96.7%); 20/25 (80%) had no RD before HSCT. CONCLUSION The RP2D of CPX-351 is 135 units/m2/dose on days 1, 3, and 5. Toxicity was manageable, and protocol therapy was effective. Response rates are superior to prior published North American cooperative group clinical trials for children with AML in first relapse.
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Affiliation(s)
- Todd M Cooper
- Department of Hematology/Oncology, Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA
| | | | - Todd A Alonzo
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | | | - Kasey J Leger
- Department of Hematology/Oncology, Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA
| | | | - Jessica Pollard
- Dana-Farber Cancer Institute/Boston Children's Hospital, Boston, MA
| | - Bassem I Razzouk
- Peyton Manning Children's Hospital at St Vincent, Indianapolis, IN
| | | | - E Anders Kolb
- Nemours Center for Cancer and Blood Disorders/Alfred I. DuPont Hospital for Children, Wilmington, DE
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Chen X, Pan J, Wang S, Hong S, Hong S, He S. The Epidemiological Trend of Acute Myeloid Leukemia in Childhood: a Population-Based Analysis. J Cancer 2019; 10:4824-4835. [PMID: 31598153 PMCID: PMC6775523 DOI: 10.7150/jca.32326] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 06/26/2019] [Indexed: 12/18/2022] Open
Abstract
Acute myeloid leukemia (AML) is the fifth most common malignancy in children, and the prognosis for AML in children remains relatively poor. However, its incidence and survival trends based on a large sample size have not been reported. Children diagnosed with AML between 1975 and 2014 were accessed from the Surveillance, Epidemiology, and End Results database. Incidence and survival trends were evaluated by age-adjusted incidence and relative survival rates (RSRs) and Kaplan-Meier analyses. Cox regression was performed to identify independent risk factors for child AML death. The overall incidence of AML in childhood increased each decade between 1975 and 2014, with the total age-adjusted incidence increasing from 5.766 to 6.615 to 7.478 to 7.607 per 1,000,000 persons. In addition, the relative survival rates of AML in childhood improved significantly, with 5-year RSRs increasing from 22.40% to 39.60% to 55.50% to 68.30% over the past four decades (p < 0.0001). Furthermore, survival disparities among different races and socioeconomic statuses have continued to widen over the past four decades. Multivariate Cox regression analyses showed a higher risk of death in Black patients (HR = 1.245, 95% CI: 1.077-1.438, p = 0.003) with Whites as a reference. These results may help predict future trends for AML in childhood, better design clinical trials by eliminating disparities, and ultimately improve clinical management and outcome.
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Affiliation(s)
- Xuanwei Chen
- Department of Pediatric, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Science, Guangzhou 510080, Guangdong, China
| | - Jianwei Pan
- Department of Pediatric, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Science, Guangzhou 510080, Guangdong, China
| | - Shuncong Wang
- Theragnostic Laboratory, Department of Imaging and Pathology, Biomedical Sciences Group, KU Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Shandie Hong
- Department of Neonatal Intensive Care, Chaozhou People's Hospital, Chaozhou 521000, Guangdong, China
| | - Shunrong Hong
- Department of Radiology, Puning People's Hospital, Puning 515300, Guangdong, China
| | - Shaoru He
- Department of Pediatric, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Science, Guangzhou 510080, Guangdong, China
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7
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Getz KD, Sung L, Ky B, Gerbing RB, Leger KJ, Leahy AB, Sack L, Woods WG, Alonzo T, Gamis A, Aplenc R. Occurrence of Treatment-Related Cardiotoxicity and Its Impact on Outcomes Among Children Treated in the AAML0531 Clinical Trial: A Report From the Children's Oncology Group. J Clin Oncol 2019; 37:12-21. [PMID: 30379624 PMCID: PMC6354770 DOI: 10.1200/jco.18.00313] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2018] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Late cardiotoxicity after pediatric acute myeloid leukemia therapy causes substantial morbidity and mortality. The impact of early-onset cardiotoxicity on treatment outcomes is less well understood. Thus, we evaluated the risk factors for incident early cardiotoxicity and the impacts of cardiotoxicity on event-free survival (EFS) and overall survival (OS). METHODS Cardiotoxicity was ascertained through adverse event monitoring over the course of follow-up among 1,022 pediatric patients with acute myeloid leukemia treated in the Children's Oncology Group trial AAML0531. It was defined as grade 2 or higher left ventricular systolic dysfunction on the basis of Common Terminology Criteria for Adverse Events (version 3) definitions. RESULTS Approximately 12% of patients experienced cardiotoxicity over a 5-year follow-up, with more than 70% of incident events occurring during on-protocol therapy. Documented cardiotoxicity during on-protocol therapy was significantly associated with subsequent off-protocol toxicity. Overall, the incidence was higher among noninfants and black patients, and in the setting of a bloodstream infection. Both EFS (hazard ratio [HR], 1.6; 95% CI, 1.2 to 2.1; P = .004) and OS (HR, 1.6; 95% CI, 1.2 to 2.2, P = .005) were significantly worse in patients with documented cardiotoxicity. Impacts on EFS were equivalent whether the incident cardiotoxicity event occurred in the absence (HR, 1.6; 95% CI, 1.1 to 2.2; P = .017) or presence of infection (HR, 1.6; 95% CI, 1.0 to 2.7; P = .069) compared with patients without documented cardiotoxicity. However, the reduction in OS was more pronounced for cardiotoxicity not associated with infection (HR, 1.7; 95% CI, 1.2 to 2.5; P = .004) than for infection-associated cardiotoxicity (HR, 1.3; 95% CI, 0.7 to 2.4; P = .387). CONCLUSION Early treatment-related cardiotoxicity may be associated with decreased EFS and OS. Cardioprotective strategies are urgently needed to improve relapse risk and both short- and long-term mortality outcomes.
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Affiliation(s)
- Kelly D. Getz
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Lillian Sung
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bonnie Ky
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Leah Sack
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Todd Alonzo
- University of Southern California, Los Angeles, CA
| | - Alan Gamis
- Children’s Mercy Hospital and Clinics, Kansas City, MO
| | - Richard Aplenc
- The Children’s Hospital of Philadelphia, Philadelphia, PA
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Armenian SH, Ehrhardt MJ. Optimizing Cardiovascular Care in Children With Acute Myeloid Leukemia to Improve Cancer-Related Outcomes. J Clin Oncol 2018; 37:1-6. [PMID: 30422740 DOI: 10.1200/jco.18.01421] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 14-year-old African American female presented with fatigue, easy bruising, and fever. On examination, she had scattered bruising, lymphadenopathy, and hepatosplenomegaly. Laboratory evaluation revealed pancytopenia with peripheral blasts, and acute myeloid leukemia (AML; French-American-British M2, t[8;21][q22;q22.1]) was diagnosed on bone marrow biopsy. A baseline echocardiogram revealed normal left ventricular (LV) systolic function (ejection fraction [EF], 60%; shortening fraction [SF], 32%), and conventional chemotherapy was initiated that consisted of two cycles of remission induction (cytarabine, etoposide, and daunorubicin [50 mg/m2 × 3 days per cycle]) followed by intensification 1 (high-dose cytarabine and etoposide), intensification 2 (high-dose cytarabine and mitoxantrone [12 mg/m2/dose daily; four total doses]), and intensification 3 (high-dose cytarabine and l-asparaginase). Of note, an echocardiogram was not repeated before the start of intensification 1. During intensification 1, the patient developed Streptococcus viridans sepsis, which required 4 days in the intensive care unit with antimicrobial and inotropic support. Repeat echocardiogram after recovery from the sepsis episode demonstrated low-normal LV systolic function (EF, 53%; SF, 27%), and she subsequently began intensification 2. On day 3 of intensification 2, the patient developed afebrile tachypnea, tachycardia, and an increasing oxygen requirement. Chest x-ray revealed cardiomegaly and pulmonary vascular congestion. Cardiac troponins were normal, whereas N-terminal pro B-type natriuretic peptide was 10 times the upper limit of normal. Repeat echocardiogram showed an enlarged LV with moderate to severely depressed LV function (EF, 28%; SF, 14%). Day 4 mitoxantrone was omitted and a cardiology consult obtained.
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DeRyckere D, Lee-Sherick AB, Huey MG, Hill AA, Tyner JW, Jacobsen KM, Page LS, Kirkpatrick GG, Eryildiz F, Montgomery SA, Zhang W, Wang X, Frye SV, Earp HS, Graham DK. UNC2025, a MERTK Small-Molecule Inhibitor, Is Therapeutically Effective Alone and in Combination with Methotrexate in Leukemia Models. Clin Cancer Res 2017; 23:1481-1492. [PMID: 27649555 PMCID: PMC5354980 DOI: 10.1158/1078-0432.ccr-16-1330] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/08/2016] [Accepted: 09/08/2016] [Indexed: 11/16/2022]
Abstract
Purpose: MERTK tyrosine kinase is ectopically expressed in 30% to 50% of acute lymphoblastic leukemias (ALL) and more than 80% of acute myeloid leukemias (AML) and is a potential therapeutic target. Here, we evaluated the utility of UNC2025, a MERTK tyrosine kinase inhibitor, for treatment of acute leukemia.Experimental Design: Preclinical in vitro and in vivo assays using cell lines and primary leukemia patient samples were used to evaluate antileukemic effects of UNC2025.Results: UNC2025 potently inhibited prosurvival signaling, induced apoptosis, and reduced proliferation and colony formation in MERTK-expressing ALL and AML cell lines and patient samples. Approximately 30% of primary leukemia patient samples (78 of 261 total) were sensitive to UNC2025. Sensitive samples were most prevalent in the AML, T-ALL, and minimally differentiated (M0) AML subsets. UNC2025 inhibited MERTK in bone marrow leukemia cells and had significant therapeutic effects in xenograft models, with dose-dependent decreases in tumor burden and consistent two-fold increases in median survival, irrespective of starting disease burden. In a patient-derived AML xenograft model, treatment with UNC2025 induced disease regression. In addition, UNC2025 increased sensitivity to methotrexate in vivo, suggesting that addition of MERTK-targeted therapy to current cytotoxic regimens may be particularly effective and/or allow for chemotherapy dose reduction.Conclusions: The broad-spectrum activity mediated by UNC2025 in leukemia patient samples and xenograft models, alone or in combination with cytotoxic chemotherapy, supports continued development of MERTK inhibitors for treatment of leukemia. Clin Cancer Res; 23(6); 1481-92. ©2016 AACR.
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Affiliation(s)
- Deborah DeRyckere
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Alisa B Lee-Sherick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Madeline G Huey
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Amanda A Hill
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jeffrey W Tyner
- Department of Cell, Developmental and Cancer Biology, Oregon Health and Science University, Knight Cancer Institute, Portland, Oregon
| | - Kristen M Jacobsen
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University, Atlanta, Georgia
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lauren S Page
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gregory G Kirkpatrick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Fatma Eryildiz
- Institute of Environmental Health and Division of Environmental and Biomolecular Systems, Oregon Health and Science University, Portland, Oregon
| | - Stephanie A Montgomery
- Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Weihe Zhang
- Center for Integrative Chemical Biology and Drug Discovery, Division of Chemical Biology and Medicinal Chemistry, Eshelman School of Pharmacy, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Xiaodong Wang
- Center for Integrative Chemical Biology and Drug Discovery, Division of Chemical Biology and Medicinal Chemistry, Eshelman School of Pharmacy, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Stephen V Frye
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Center for Integrative Chemical Biology and Drug Discovery, Division of Chemical Biology and Medicinal Chemistry, Eshelman School of Pharmacy, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - H Shelton Earp
- Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Departments of Medicine and Pharmacology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Douglas K Graham
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.
- Department of Pediatrics, Emory University, Atlanta, Georgia
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10
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von Korn P, Vogt M, Oberhoffer R, Ewert P, Müller J. Juvenile competitive triathlete after cardiotoxic anthracycline therapy for Acute Myeloid Leukemia. CARDIO-ONCOLOGY 2016; 2:8. [PMID: 33530145 PMCID: PMC7837142 DOI: 10.1186/s40959-016-0016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/15/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The treatment of Acute Myeloid Leukemia (AML) leads to several functional limitations. Especially cardiac burden following cardiotoxic chemotherapy, which limits exercise and competitive sport in the long-term survivors. SUBJECT AND METHODS We report on a young female amateur triathlete born in 1997, who was diagnosed with AML at the age of fifteen. She had chemotherapy with a cumulative dose of about 1000 mg/m2 anthracyclines and allogeneic stem cell transplantation which was successful, but she suffered from cardiotoxic systolic heart failure with a left ventricular ejection fraction (LVEF) <55 % and an impaired peak oxygen uptake of 23.2 ml/min/kg and 53 % of predicted, respectively. After medical examination and counselling with a sport scientist she started a tailored training of aerobic exercise. She was evaluated at regular intervals which resulted in increasing the training load and volume. Eventually her training hours was stepwise increased to 12 h training per week, which includes high intensity intervals. RESULTS Within almost 3 years, her exercise performance improved tremendously. Workload doubled from 2.1 W/kg to 4.2 W/kg, peak oxygen uptake increased from 23.2 ml/min/kg to 49.1 ml/min/kg and from 53 to 135 %, respectively. Moreover, she participated in several competitions. However, LVEF remains almost unchanged. CONCLUSION With the right training and under medical surveillance competitive exercise with an anthracycline-damaged heart is still achievable. Moreover, competitive training and exercise seems to be safe and feasible.
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Affiliation(s)
- Pia von Korn
- Institute of Preventive Pediatrics, Technische Universität München, Munich, Germany
| | - Manfred Vogt
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, D-80636, Munich, Germany
| | - Renate Oberhoffer
- Institute of Preventive Pediatrics, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, D-80636, Munich, Germany
| | - Jan Müller
- Institute of Preventive Pediatrics, Technische Universität München, Munich, Germany. .,Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, D-80636, Munich, Germany.
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11
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Jarfelt M, Andersen NH, Hasle H. Is it possible to cure childhood acute myeloid leukaemia without significant cardiotoxicity? Br J Haematol 2016; 175:577-587. [PMID: 27739070 DOI: 10.1111/bjh.14374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Since cardiotoxicity is a life threatening late effect, a reduction of cardiotoxicity in the treatment of acute myeloid leukaemia (AML) is essential. This review is a compilation of the current knowledge about cardiotoxicity after AML treatment and of how future directions in treatment may affect its incidence. A total of six studies concerning AML and cardiotoxicity were identified. The incidence of late subclinical cardiotoxicity varied between 1·3 and 15·3%, and late clinical cardiotoxicity varied between 1·3 and 9·3%. Cumulative dose of anthracyclines (ACs) and history of relapse were the most common risk factors identified. No conclusions could be drawn about new, potentially less toxic ACs. Differences in treatment data and variations in study populations made comparisons uncertain. The echocardiographic techniques used in the majority of the studies are inferior to more modern echocardiographic methods. This decreases reproducibility and may increase the risk of overestimation of cardiotoxicity. In summary, AML cannot be cured today without ACs. However, some ACs may cause less cardiotoxicity than others. Furthermore there is currently no consensus on equipotent doses of ACs and risk factors for cardiotoxicity. Further research including randomized trials is needed to evaluate whether or not the potentially less cardiotoxic agents fulfil their promise.
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Affiliation(s)
- Marianne Jarfelt
- Department of Paediatric Oncology and Haematology, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Niels H Andersen
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Skejby, Denmark
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12
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Kero A, Madanat-Harjuoja L, Järvelä L, Malila N, Matomäki J, Lähteenmäki P. Cardiovascular medication after cancer at a young age in Finland: A nationwide registry linkage study. Int J Cancer 2015; 139:683-90. [DOI: 10.1002/ijc.29943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/18/2015] [Indexed: 12/23/2022]
Affiliation(s)
- A.E. Kero
- Department of Pediatric and Adolescent Medicine; Turku University Hospital and Turku University; Turku Finland
| | - L.M. Madanat-Harjuoja
- Department of Pediatrics; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Finnish Cancer Registry; Helsinki Finland
| | - L.S. Järvelä
- Department of Pediatric and Adolescent Medicine; Turku University Hospital and Turku University; Turku Finland
| | - N. Malila
- Finnish Cancer Registry; Helsinki Finland
- School of Health Sciences; University of Tampere; Tampere Finland
| | - J. Matomäki
- Turku Clinical Research Center, Turku University Hospital; Finland
| | - P.M. Lähteenmäki
- Department of Pediatric and Adolescent Medicine; Turku University Hospital and Turku University; Turku Finland
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13
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Jarfelt M, Andersen NH, Glosli H, Jahnukainen K, Jónmundsson GK, Malmros J, Nysom K, Hasle H. Cardiac function in survivors of childhood acute myeloid leukemia treated with chemotherapy only: a NOPHO-AML study. Eur J Haematol 2015; 97:55-62. [PMID: 26383901 DOI: 10.1111/ejh.12683] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2015] [Indexed: 12/24/2022]
Abstract
OBJECTIVES We report cardiac function of patients treated for Childhood acute myeloid leukemia with chemotherapy only according to three consecutive Nordic protocols. METHODS Ninety-eight of 138 eligible patients accepted examination with standardized echocardiography. Results were compared with age- and sex-matched controls. RESULTS The median age was 3 yr at diagnosis (range 0-15), and the median time from diagnosis to study was 11 yr (4-25). All but one patient had received doxorubicin and 90% had received mitoxantrone. The median cumulative dose of daunorubicin equivalents was 300 mg/m(2) (210-525). Left ventricular fractional shortening (LVFS) and ejection fraction (LVEF) were lower in patients than in controls (32.6% (SD 4.0) vs. 35.2% (SD 3.4), P = 0.002 and 59.9% (SD 5.5) vs. 64.2% (SD 4.4), P = 0.001). The myocardial performance index (MPI) was higher in patients than in controls (0.32 (SD 0.081) vs. 0.26 (SD 0.074), P < 0.0001). Cumulative dose of doxorubicin but not mitoxantrone was related to lower LVFS (P = 0.037) and LVEF (P = 0.016). Longer follow-up was associated with lower LVFS (P = 0.034). Higher MPI was associated with young age at diagnosis (P = 0.04) and longer follow-up (P = 0.031). CONCLUSIONS In this study, most patients had cardiac function within normal limits and reported very few cardiac symptoms. However, compared with healthy controls, they had significantly reduced left ventricular function.
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Affiliation(s)
- Marianne Jarfelt
- Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Niels H Andersen
- Department of Internal Medicine, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Heidi Glosli
- Department of Pediatrics, University Hospital Oslo, Rikshospitalet, Oslo, Norway
| | | | | | - Johan Malmros
- Department of Pediatric Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Karsten Nysom
- Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
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14
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Krystal JI, Reppucci M, Mayr T, Fish JD, Sethna C. Arterial stiffness in childhood cancer survivors. Pediatr Blood Cancer 2015; 62:1832-7. [PMID: 25895119 DOI: 10.1002/pbc.25547] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/16/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Cardiovascular disease is prevalent among childhood cancer survivors (CCS). Arterial stiffness measured by pulse wave velocity (PWV) may be predictive of cardiovascular morbidity. Increased PWV has been seen in adults following chemotherapy. PURPOSE To evaluate PWV in a cohort of CCS and healthy controls. PATIENTS AND METHODS All participants were >6 years old. CCS were >12 months off-therapy and free of cardiac disease, diabetes, and kidney dysfunction. Height, weight, blood pressure (BP), medications, cancer diagnosis, age at diagnosis, time off therapy, chemotherapy, and radiation exposures were recorded. PWV was measured on all participants. RESULTS Sixty-eight CCS (mean 17.3 ± 6 years, 52.9% male), and 51 controls (mean 18.4 ± 5.5 years, 37.3% male) were evaluated. Among CCS, 34% had lymphoma, 44% leukemia, and 22% solid tumors, and 49% were exposed to radiation. CCS were off therapy 7 ± 4.2 years. Both groups were statistically similar in age, BMI, and BP. CCS ≥ 18 years old had significantly higher PWV compared to controls ≥ 18 years old (6.37 ± 0.89 vs. 5.76 ± 0.88 m/sec, P = 0.012). The relationship persisted in a regression model adjusted for age, sex, and BMI z-score (β = 0.52, 95%CI 0.051-0.979, P = 0.03). Seventy percent of CCS ≥ 18 had elevated PWV compared to established norms. Radiation therapy, anthracycline dose, and chemotherapy exposures were not predictive of increased PWV in CCS. CONCLUSIONS CCS ≥ 18 demonstrated prematurely elevated PVW. Further studies are needed to determine the predictive value of PWV in this population and its utility as a screening modality.
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Affiliation(s)
- Julie I Krystal
- Division of Pediatric Hematology-Oncology, Cohen Children's Medical Center, New Hyde Park, New York, 11040
| | - Marina Reppucci
- Hofstra Northshore-LIJ School of Medicine, Hempstead, New York
| | - Theresa Mayr
- Division of Pediatric Hematology-Oncology, Cohen Children's Medical Center, New Hyde Park, New York, 11040
| | - Jonathan D Fish
- Division of Pediatric Hematology-Oncology, Cohen Children's Medical Center, New Hyde Park, New York, 11040
| | - Christine Sethna
- Division of Pediatric Nephrology, Cohen Children's Medical Center, New Hyde Park, New York
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15
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Abstract
Cardiovascular complications are among the leading causes of morbidity and mortality among survivors of childhood cancer, after cancer relapse and secondary malignancies. Although advances in cancer treatment have improved the 5-year survival rates, the same treatments, such as anthracyclines, that cure cancer also increase the risk for adverse cardiovascular effects. Anthracycline-related cardiotoxicity in survivors of childhood cancer is progressive and can take years to develop, initially presenting as sub-clinical cardiac abnormalities that, if left undetected or untreated, can lead to heart failure, myocardial infarction, or other clinical cardiac dysfunction. A higher cumulative dose of anthracycline is associated with cardiotoxicity in children; however, sub-clinical cardiac abnormalities are evident at lower doses with longer follow-up, suggesting that there is no "safe" dose of anthracycline. Other risk factors include female sex, younger age at diagnosis, black race, trisomy 21, longer time since treatment, and the presence of pre-existing cardiovascular disease and co-morbidities. Cardioprotective strategies during treatment are limited in children. Enalapril provides only temporary cardioprotection, whereas continuous anthracycline infusion extends none. On the other hand, dexrazoxane successfully prevents or reduces anthracycline-related cardiotoxicity in children with cancer, without increased risks for recurrence of primary or second malignancies or reductions in anti-tumour efficacy. With more childhood cancer survivors now reaching adulthood, it is vital to understand the adverse effects of cancer treatment on the cardiovascular system and their long-term consequences to identify and establish optimal prevention and management strategies that balance oncologic efficacy with long-term safety.
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16
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Lee-Sherick AB, Zhang W, Menachof KK, Hill AA, Rinella S, Kirkpatrick G, Page LS, Stashko MA, Jordan CT, Wei Q, Liu J, Zhang D, DeRyckere D, Wang X, Frye S, Earp HS, Graham DK. Efficacy of a Mer and Flt3 tyrosine kinase small molecule inhibitor, UNC1666, in acute myeloid leukemia. Oncotarget 2015; 6:6722-36. [PMID: 25762638 PMCID: PMC4466645 DOI: 10.18632/oncotarget.3156] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/15/2015] [Indexed: 01/28/2023] Open
Abstract
Mer and Flt3 receptor tyrosine kinases have been implicated as therapeutic targets in acute myeloid leukemia (AML). In this manuscript we describe UNC1666, a novel ATP-competitive small molecule tyrosine kinase inhibitor, which potently diminishes Mer and Flt3 phosphorylation in AML. Treatment with UNC1666 mediated biochemical and functional effects in AML cell lines expressing Mer or Flt3 internal tandem duplication (ITD), including decreased phosphorylation of Mer, Flt3 and downstream effectors Stat, Akt and Erk, induction of apoptosis in up to 98% of cells, and reduction of colony formation by greater than 90%, compared to treatment with vehicle. These effects were dose-dependent, with inhibition of downstream signaling and functional effects correlating with the degree of Mer or Flt3 kinase inhibition. Treatment of primary AML patient samples expressing Mer and/or Flt3-ITD with UNC1666 also inhibited Mer and Flt3 intracellular signaling, induced apoptosis, and inhibited colony formation. In summary, UNC1666 is a novel potent small molecule tyrosine kinase inhibitor that decreases oncogenic signaling and myeloblast survival, thereby validating dual Mer/Flt3 inhibition as an attractive treatment strategy for AML.
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Affiliation(s)
| | - Weihe Zhang
- University of North Carolina, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | | | - Amanda A. Hill
- University of Colorado, Department of Pediatrics, Aurora, CO, USA
| | - Sean Rinella
- University of Colorado, Department of Pediatrics, Aurora, CO, USA
| | | | - Lauren S. Page
- University of Colorado, Department of Pediatrics, Aurora, CO, USA
| | - Michael A. Stashko
- University of North Carolina, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Craig T. Jordan
- University of Colorado, Department of Medicine, Aurora, CO, USA
| | - Qi Wei
- Children's Hospital Colorado, Department of Pathology, Aurora, CO, USA
| | - Jing Liu
- University of North Carolina, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Dehui Zhang
- University of North Carolina, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | | | - Xiaodong Wang
- University of North Carolina, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Stephen Frye
- University of North Carolina, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - H. Shelton Earp
- University of North Carolina, Department of Medicine, Chapel Hill, NC, USA
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17
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Zhang L, Samad A, Pombo-de-Oliveira MS, Scelo G, Smith MT, Feusner J, Wiemels JL, Metayer C. Global characteristics of childhood acute promyelocytic leukemia. Blood Rev 2015; 29:101-25. [PMID: 25445717 PMCID: PMC4379131 DOI: 10.1016/j.blre.2014.09.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/21/2014] [Accepted: 09/23/2014] [Indexed: 12/29/2022]
Abstract
Acute promyelocytic leukemia (APL) comprises approximately 5-10% of childhood acute myeloid leukemia (AML) cases in the US. While variation in this percentage among other populations was noted previously, global patterns of childhood APL have not been thoroughly characterized. In this comprehensive review of childhood APL, we examined its geographic pattern and the potential contribution of environmental factors to observed variation. In 142 studies (spanning >60 countries) identified, variation was apparent-de novo APL represented from 2% (Switzerland) to >50% (Nicaragua) of childhood AML in different geographic regions. Because a limited number of previous studies addressed specific environmental exposures that potentially underlie childhood APL development, we gathered 28 childhood cases of therapy-related APL, which exemplified associations between prior exposures to chemotherapeutic drugs/radiation and APL diagnosis. Future population-based studies examining childhood APL patterns and the potential association with specific environmental exposures and other risk factors are needed.
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Affiliation(s)
- L Zhang
- School of Public Health, University of California, Berkeley, USA.
| | - A Samad
- School of Public Health, University of California, Berkeley, USA.
| | - M S Pombo-de-Oliveira
- Pediatric Hematology-Oncology Program, Research Center-National Institute of Cancer, Rio de Janeiro, Brazil.
| | - G Scelo
- International Agency for Research on Cancer (IARC), Lyon, France.
| | - M T Smith
- School of Public Health, University of California, Berkeley, USA.
| | - J Feusner
- Department of Hematology, Children's Hospital and Research Center Oakland, Oakland, USA.
| | - J L Wiemels
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA.
| | - C Metayer
- School of Public Health, University of California, Berkeley, USA.
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18
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Lipshultz SE, Diamond MB, Franco VI, Aggarwal S, Leger K, Santos MV, Sallan SE, Chow EJ. Managing chemotherapy-related cardiotoxicity in survivors of childhood cancers. Paediatr Drugs 2014; 16:373-89. [PMID: 25134924 PMCID: PMC4417358 DOI: 10.1007/s40272-014-0085-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the US, children diagnosed with cancer are living longer, but not without consequences from the same drugs that cured their cancer. In these patients, cardiovascular disease is the leading cause of non-cancer-related morbidity and mortality. Although this review focuses on anthracycline-related cardiomyopathy in childhood cancer survivors, the global lifetime risk of other cardiovascular diseases such as atherosclerosis, arrhythmias and intracardiac conduction abnormalities, hypertension, and stroke also are increased. Besides anthracyclines, newer molecularly targeted agents, such as vascular endothelial growth factor receptor and tyrosine kinase inhibitors, also have been associated with acute hypertension, cardiomyopathy, and increased risk of ischemic cardiac events and arrhythmias, and are summarized here. This review also covers other risk factors for chemotherapy-related cardiotoxicity (including both modifiable and non-modifiable factors), monitoring strategies (including both blood and imaging-based biomarkers) during and following cancer treatment, and discusses the management of cardiotoxicity (including prevention strategies such as cardioprotection by use of dexrazoxane).
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Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine and the Children's Research Center of Michigan at the Children's Hospital of Michigan, 3901 Beaubien Boulevard, Suite 1K40, Detroit, MI, 48201, USA,
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19
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Kaspers G. How I treat paediatric relapsed acute myeloid leukaemia. Br J Haematol 2014; 166:636-45. [PMID: 24837715 DOI: 10.1111/bjh.12947] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/10/2014] [Indexed: 11/28/2022]
Abstract
The prognosis of paediatric acute myeloid leukaemia (AML) has improved significantly over the recent decades, but still about one-third of patients relapse. These patients have a relatively poor prognosis, with a probability of long-term survival from relapse of about 35%. This can only be achieved with very intensive chemotherapy and, usually, allogeneic stem cell transplantation, leading to very significant toxicity and even treatment-related mortality. Major improvements in the treatment of paediatric relapsed AML thus are required still, and several possibilities are discussed. In case of a suspected relapse, a comprehensive diagnostic work-up has to be undertaken, because significant changes in the biological features of the AML cells may have occurred between initial diagnosis and relapse. This review discusses many practical issues that one encounters in the treatment of children with relapsed AML. It will also be of interest for those involved in translational research in AML.
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Affiliation(s)
- Gertjan Kaspers
- Paediatric Oncology/Haematology, VU University Medical Center, Amsterdam, The Netherlands
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20
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Cooper TM, Alonzo TA, Gerbing RB, Perentesis JP, Whitlock JA, Taub JW, Horton TM, Gamis AS, Meshinchi S, Loken MR, Razzouk BI. AAML0523: a report from the Children's Oncology Group on the efficacy of clofarabine in combination with cytarabine in pediatric patients with recurrent acute myeloid leukemia. Cancer 2014; 120:2482-9. [PMID: 24771494 DOI: 10.1002/cncr.28674] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 12/19/2013] [Accepted: 01/09/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND The discovery of new, effective non-anthracycline-based reinduction regimens for children with recurrent acute myeloid leukemia (AML) is critical. In this phase 1/2 study, the tolerability and overall response rate of clofarabine in combination with cytarabine was investigated in children with recurrent/refractory AML. METHODS AAML0523 enrolled 49 children with AML in first recurrence or who were refractory to induction therapy. The study consisted of a dose-finding phase (9 patients) and an efficacy phase (40 patients). Two children received clofarabine at a dose of 40 mg/m(2)/day and 47 children at a dose of 52 mg/m(2)/day. RESULTS Toxicities typical for intensive chemotherapy regimens were observed at all doses of clofarabine. The recommended pediatric phase 2 dose of clofarabine in combination with cytarabine was 52 mg/m(2)/day for 5 days. Of 48 evaluable patients, the overall response rate (complete remission plus complete remission with partial platelet recovery) was 48%. Four patients met conventional criteria for complete remission with incomplete count recovery. Twenty-one of 23 responders subsequently underwent hematopoietic stem cell transplantation. The overall survival rate at 3 years was 46% for responders compared with 16% for nonresponders (P < .001). Patients found to have no minimal residual disease at the end of the first cycle by flow cytometric analysis had superior overall survival after 1 year (100% vs 38%; P = .01). CONCLUSIONS The combination of clofarabine and cytarabine yielded an acceptable response rate without excess toxicity in children with recurrent AML. The nearly 50% survival rate reported in responders is highly encouraging in these high-risk patients and suggests that this combination is an effective bridge to hematopoietic stem cell transplantation.
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Affiliation(s)
- Todd M Cooper
- Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Service, Emory University, Atlanta, Georgia
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21
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Ward E, DeSantis C, Robbins A, Kohler B, Jemal A. Childhood and adolescent cancer statistics, 2014. CA Cancer J Clin 2014; 64:83-103. [PMID: 24488779 DOI: 10.3322/caac.21219] [Citation(s) in RCA: 1506] [Impact Index Per Article: 150.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/09/2013] [Indexed: 12/11/2022] Open
Abstract
In this article, the American Cancer Society provides estimates of the number of new cancer cases and deaths for children and adolescents in the United States and summarizes the most recent and comprehensive data on cancer incidence, mortality, and survival from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries (which are reported in detail for the first time here and include high-quality data from 45 states and the District of Columbia, covering 90% of the US population). In 2014, an estimated 15,780 new cases of cancer will be diagnosed and 1960 deaths from cancer will occur among children and adolescents aged birth to 19 years. The annual incidence rate of cancer in children and adolescents is 186.6 per 1 million children aged birth to 19 years. Approximately 1 in 285 children will be diagnosed with cancer before age 20 years, and approximately 1 in 530 young adults between the ages of 20 and 39 years is a childhood cancer survivor. It is therefore likely that most pediatric and primary care practices will be involved in the diagnosis, treatment, and follow-up of young patients and survivors. In addition to cancer statistics, this article will provide an overview of risk factors, symptoms, treatment, and long-term and late effects for common pediatric cancers.
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Affiliation(s)
- Elizabeth Ward
- National Vice President, Intramural Research, American Cancer Society, Atlanta, GA
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22
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Abstract
Treatment advances and higher participation rates in clinical trials have rapidly increased the number of survivors of childhood cancer. However, chemotherapy and radiation treatments are cardiotoxic and can cause cardiomyopathy, conduction defects, myocardial infarction, hypertension, stroke, pulmonary oedema, dyspnoea and exercise intolerance later in life. These cardiotoxic effects are often progressive and irreversible, emphasizing a need for effective prevention and treatment to reduce or avoid cardiotoxicity. Medical interventions, such as angiotensin-converting enzyme inhibitors, β-blockers, and growth hormone therapy, might be used to treat cardiotoxicity in childhood cancer survivors. Preventative strategies should include the use of dexrazoxane, which provides cardioprotection without reducing the oncological efficacy of doxorubicin chemotherapy; less-toxic anthracycline derivatives and the use of antioxidant nutritional supplements might also be beneficial. Continuous-infusion doxorubicin provides no benefit over bolus infusion in children. Identifying patient-related (for example, obesity and hypertension) and drug-related (for example, cumulative dose) risk factors for cardiotoxicity could help tailor treatments to individual patients. However, all survivors of childhood cancer are at increased risk of cardiotoxicity, suggesting that survivor screening recommendations for assessment of global risk of premature cardiovascular disease should apply to all survivors. Optimal, evidence-based monitoring strategies and multiagent preventative treatments still need to be identified.
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Lipshultz SE, Franco VI, Cochran TR. Cardiotoxicity in childhood cancer survivors: a problem with long-term consequences in need of early detection and prevention. Pediatr Blood Cancer 2013; 60:1395-6. [PMID: 23712966 DOI: 10.1002/pbc.24597] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 04/22/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida 33101, USA.
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