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Edwards LA, Yang C, Sharma S, Chen ZH, Gorantla L, Joshi SA, Longhi NJ, Worku N, Yang JS, Martinez Di Pietro B, Armenian S, Bhat A, Border W, Buddhe S, Blythe N, Stratton K, Leger KJ, Leisenring WM, Meacham LR, Nathan PC, Narasimhan S, Sachdeva R, Sadak K, Chow EJ, Boyle PM. Building a machine learning-assisted echocardiography prediction tool for children at risk for cancer therapy-related cardiomyopathy. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:66. [PMID: 39385257 PMCID: PMC11462765 DOI: 10.1186/s40959-024-00268-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 09/25/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Despite routine echocardiographic surveillance for childhood cancer survivors, the ability to predict cardiomyopathy risk in individual patients is limited. We explored the feasibility and optimal processes for machine learning-enhanced cardiomyopathy prediction in survivors using serial echocardiograms from five centers. METHODS We designed a series of deep convolutional neural networks (DCNNs) for prediction of cardiomyopathy (shortening fraction ≤ 28% or ejection fraction ≤ 50% on two occasions) for at-risk survivors ≥ 1-year post initial cancer therapy. We built DCNNs with four subsets of echocardiographic data differing in timing relative to case (survivor who developed cardiomyopathy) index diagnosis and two input formats (montages) with differing image selections. We used holdout subsets in a 10-fold cross-validation framework and standard metrics to assess model performance (e.g., F1-score, area under the precision-recall curve [AUPRC]). Performance of the input formats was compared using a combined 5 × 2 cross-validation F-test. RESULTS The dataset included 542 pairs of montages: 171 montage pairs from 45 cases at time of cardiomyopathy diagnosis or pre-diagnosis and 371 pairs from 70 at-risk survivors who didn't develop cardiomyopathy during follow-up (non-case). The DCNN trained to distinguish between non-case and time of cardiomyopathy diagnosis or pre-diagnosis case montages achieved an AUROC of 0.89 ± 0.02, AUPRC 0.83 ± 0.03, and F1-score: 0.76 ± 0.04. When limited to smaller subsets of case data (e.g., ≥ 1 or 2 years pre-diagnosis), performance worsened. Model input format did not impact performance accuracy across models. CONCLUSIONS This methodology is a promising first step toward development of a DCNN capable of accurately differentiating pre-diagnosis versus non-case echocardiograms to predict survivors more likely to develop cardiomyopathy.
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Affiliation(s)
- Lindsay A Edwards
- Department of Pediatrics, Division of Cardiology, Duke University Medical Center, DUMC Box 3090, Durham, NC, 27710, USA.
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | | | - Surbhi Sharma
- Department of Bioengineering, University of Washington, 3720 15th Ave NE N361, UW Mailbox 355061, Seattle, WA, 98195, USA
| | - Zih-Hua Chen
- Department of Bioengineering, University of Washington, 3720 15th Ave NE N361, UW Mailbox 355061, Seattle, WA, 98195, USA
| | - Lahari Gorantla
- Department of Bioengineering, University of Washington, 3720 15th Ave NE N361, UW Mailbox 355061, Seattle, WA, 98195, USA
| | - Sanika A Joshi
- Department of Bioengineering, University of Washington, 3720 15th Ave NE N361, UW Mailbox 355061, Seattle, WA, 98195, USA
| | - Nicolas J Longhi
- Department of Bioengineering, University of Washington, 3720 15th Ave NE N361, UW Mailbox 355061, Seattle, WA, 98195, USA
| | - Nahom Worku
- Department of Bioengineering, University of Washington, 3720 15th Ave NE N361, UW Mailbox 355061, Seattle, WA, 98195, USA
| | - Jamie S Yang
- Department of Bioengineering, University of Washington, 3720 15th Ave NE N361, UW Mailbox 355061, Seattle, WA, 98195, USA
| | | | - Saro Armenian
- Departments of Pediatrics and Population Sciences, City of Hope, Duarte, CA, USA
| | - Aarti Bhat
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
| | - William Border
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Sujatha Buddhe
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Nancy Blythe
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Kayla Stratton
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Kasey J Leger
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
| | - Wendy M Leisenring
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Lillian R Meacham
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Paul C Nathan
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Shanti Narasimhan
- Department of Pediatrics, University of Minnesota, Masonic Children's Hospital, Minneapolis, MN, USA
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Sadak
- Department of Pediatrics, University of Minnesota, Masonic Children's Hospital, Minneapolis, MN, USA
| | - Eric J Chow
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Patrick M Boyle
- Department of Bioengineering, University of Washington, 3720 15th Ave NE N361, UW Mailbox 355061, Seattle, WA, 98195, USA.
- Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, USA.
- Center for Cardiovascular Biology, University of Washington, Seattle, WA, USA.
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Mo Z, Deng Y, Bao Y, Liu J, Jiang Y. Evaluation of cardiotoxicity of anthracycline-containing chemotherapy regimens in patients with bone and soft tissue sarcomas: A study of the FDA adverse event reporting system joint single-center real-world experience. Cancer Med 2023; 12:21709-21724. [PMID: 38054208 PMCID: PMC10757145 DOI: 10.1002/cam4.6730] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/24/2023] [Accepted: 11/07/2023] [Indexed: 12/07/2023] Open
Abstract
OBJECTIVES To assess the occurrence of cardiotoxicity in patients with tumors receiving anthracycline-based chemotherapy, especially for sarcomas. METHODS This study summarized the types and frequency of adverse events (AEs) for three anthracyclines from the FDA adverse event reporting system (FAERS) database. FAERS data from January 2004 to June 2022 were collected and analyzed. Disproportionality analyses, logistic regression, and descriptive analysis were used to compare the differences in cardiac disorders. A retrospective cohort study was conducted in a single center between December 2008 and May 2022. Our hospital-treated patients with bone and soft tissue sarcomas (BSTSs) with anthracycline-containing chemotherapy were analyzed. Serum markers, echocardiography, and electrocardiography have been used to evaluate cardiotoxic events. RESULTS One hundred thousand and seventy-five AE reports were obtained for doxorubicin (ADM), epirubicin (EPI), and liposome doxorubicin (L-ADM) from the FAERS database. ADM (OR = 3.1, p < 0.001), EPI (OR = 1.5, p < 0.001), and sarcomas (OR = 1.8, p < 0.001) may increase the probability of cardiac disorders. Cardiac failure, cardiotoxicity, and cardiomyopathy were anthracyclines' top 3 frequent AEs. Among patients receiving ADM-containing therapy, those with ADM applied at doses ≥75 mg/m2 /cycle were more likely to develop cardiac disorders than the other subgroups (OR = 3.5, p < 0.001). Patients younger than 18 are more likely to benefit from dexrazoxane prevention of cardiac failure. Six hundred and eighty-three patients with BSTSs receiving anthracycline-based chemotherapy were analyzed in our center. Patients receiving ADM-containing chemotherapy were likelier to experience abnormalities in serum troponin-T and left ventricular ejection fraction (p < 0.05). 2.0% (6/300) of patients receiving ADM-containing chemotherapy required adjustment of the chemotherapy regimen because of cardiotoxicity, whereas none were in the EPI or L-ADM groups. CONCLUSIONS AND RELEVANCE Among patients receiving anthracycline-containing therapy, patients with BSTSs were more likely to develop cardiac disorders than other tumors. In addition, patients with BSTSs receiving ADM chemotherapy had a higher likelihood of cardiotoxic events than those receiving EPI or L-ADM.
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Affiliation(s)
- Zeming Mo
- Division of Medical Oncology, Cancer Center, West China HospitalSichuan UniversityChengduChina
| | - Yaotiao Deng
- Division of Medical Oncology, Cancer Center, West China HospitalSichuan UniversityChengduChina
| | - Yiwen Bao
- Department of OncologyThe People's Hospital of QiannanDuyunGuizhouChina
| | - Jie Liu
- Division of Medical Oncology, Cancer Center, West China HospitalSichuan UniversityChengduChina
| | - Yu Jiang
- Division of Medical Oncology, Cancer Center, West China HospitalSichuan UniversityChengduChina
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3
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Bottinor WJ, Deng X, Bandyopadhyay D, Coburn G, Havens C, Carr M, Saurers D, Judkins C, Gong W, Yu C, Friedman DL, Borinstein SC, Soslow JH. Myocardial Strain during Surveillance Screening Is Associated with Future Cardiac Dysfunction among Survivors of Childhood, Adolescent and Young Adult-Onset Cancer. Cancers (Basel) 2023; 15:cancers15082349. [PMID: 37190277 DOI: 10.3390/cancers15082349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Cardiovascular disease is a leading contributor to mortality among childhood, adolescent and young adult (C-AYA) cancer survivors. While serial cardiovascular screening is recommended in this population, optimal screening strategies, including the use of echocardiography-based myocardial strain, are not fully defined. Our objective was to determine the relationship between longitudinal and circumferential strain (LS, CS) and fractional shortening (FS) among survivors. This single-center cohort study retrospectively measured LS and CS among C-AYAs treated with anthracycline/anthracenedione chemotherapy. The trajectory of LS and CS values over time were examined among two groups of survivors: those who experienced a reduction of >5 fractional shortening (FS) units from pre-treatment to the most recent echocardiogram, and those who did not. Using mixed modeling, LS and CS were used to estimate FS longitudinally. A receiver operator characteristic curve was generated to determine the ability of our model to correctly predict an FS ≤ 27%. A total of 189 survivors with a median age of 14 years at diagnosis were included. Among the two survivor groups, the trajectory of LS and CS differed approximately five years from cancer diagnosis. A statistically significant inverse relationship was demonstrated between FS and LS -0.129, p = 0.039, as well as FS and CS -0.413, p < 0.001. The area under the curve for an FS ≤ 27% was 91%. Among C-AYAs, myocardial strain measurements may improve the identification of individuals with cardiotoxicity, thereby allowing earlier intervention.
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Affiliation(s)
- Wendy J Bottinor
- Department of Internal Medicine, Division of Cardiovascular Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Xiaoyan Deng
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA 23298, USA
| | | | - Gary Coburn
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University, Nashville, TN 37232, USA
| | - Corey Havens
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University, Nashville, TN 37232, USA
| | - Melissa Carr
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University, Nashville, TN 37232, USA
| | - Daniel Saurers
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University, Nashville, TN 37232, USA
| | - Chantelle Judkins
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University, Nashville, TN 37232, USA
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University, Nashville, TN 37232, USA
| | - Debra L Friedman
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Scott C Borinstein
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Jonathan H Soslow
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University, Nashville, TN 37232, USA
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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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Watson C, Gadikota H, Barlev A, Beckerman R. A review of the risks of long-term consequences associated with components of the CHOP chemotherapy regimen. J Drug Assess 2022; 11:1-11. [PMID: 35693477 PMCID: PMC9176678 DOI: 10.1080/21556660.2022.2073101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A common chemotherapy regimen in post-transplant lymphoproliferative disease (PTLD) following solid organ transplants (SOT) is cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). This study reviews the quantitative evidence for long-term consequences associated with components of CHOP identified from the Children's Oncology Group Long-Term Follow-Up Guidelines. Cited references were screened using prespecified criteria (English, systematic review, randomized controlled trial n > 100, observation study n > 100, case series n > 20). Relevant data were extracted and synthesized. Of 61 studies, 66% were retrospective cohort studies, 28% were in the US, and 95% enrolled pediatric patients. No study focused specifically on the CHOP regimen. Long-term consequences for CHOP components observed in >3 studies included cardiac toxicity (n = 14), hormone deficiencies/infertility (n = 14), secondary leukemia (n = 7), osteonecrosis (n = 6), and bladder cancer (n = 4). These effects are significant, impact a high percentage of patients, and occur as early as one year after treatment. Although none of the studies focused specifically on the CHOP regimen, 30%, 23%, and 15% evaluated alkylating agents (e.g. cyclophosphamide), anthracyclines (e.g. doxorubicin), and corticosteroids (e.g. prednisone), respectively. All three product classes had a dose-dependent risk of long-term consequences with up to 13.2-fold, 27-fold, 16-fold, 14.5-fold, and 6.2-fold increase in risk of heart failure, early menopause, secondary leukemia, bladder cancer, and osteonecrosis, respectively. Lymphoma patients had significantly elevated risks of cardiac toxicity (up to 12.2-fold), ovarian failure (up to 3.8-fold), and osteonecrosis (up to 6.7-fold). No studies were found in PTLD or SOT. Safe and effective PTLD treatments that potentially avoid these long-term consequences are urgently needed.
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Affiliation(s)
- Crystal Watson
- Atara Biotherapeutics Inc., South San Francisco, CA, USA
| | | | - Arie Barlev
- Atara Biotherapeutics Inc., South San Francisco, CA, USA
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6
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Nathan P, Kulkarni K, MacDonald T. Incidence and risk factors of anthracycline-induced cardiotoxicity in long-term survivors of pediatric cancer: A population based cohort study. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2022. [DOI: 10.1016/j.phoj.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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7
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Sitte V, Burkhardt B, Weber R, Kretschmar O, Hersberger M, Bergsträsser E, Christmann M. Advanced Imaging and New Cardiac Biomarkers in Long-term Follow-up After Childhood Cancer. J Pediatr Hematol Oncol 2022; 44:e374-e380. [PMID: 33828032 DOI: 10.1097/mph.0000000000002156] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/04/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Pathologic ejection fraction (EF), shortening fraction (FS), and standard heart failure biomarkers (high sensitive troponin T and N-terminal brain natriuretic peptide) during follow-up after childhood cancer have been associated with irreversible cardiac damage. We aimed to evaluate strain imaging values by echocardiography and new biomarkers for heart failure with preserved ejection fraction (HFpEF) as potential more sensitive parameters for cardiac deterioration in childhood cancer survivors (CCS). MATERIALS AND METHODS Prospective study with 50 CCS (median 16.2 y) at a median follow-up of 13 years. In addition to standard echo and laboratory parameters for heart failure, strain measurements and new biomarkers, including myocardial inflammation (interleukin 6), extracellular matrix (ECM) remodeling (C-telopeptide for type I collagen, intact N-terminal propeptide of type III procollagen), and other heart failure biomarkers (galectin 3, solutable ST2, growth differentiation factor 15), were obtained and compared with 50 healthy controls. RESULTS No significant differences in EF, FS, high sensitive troponin T, N-terminal brain natriuretic peptide, interleukin 6, solutable ST2, and galectin 3 were found between study and control groups. In contrast, strain imaging showed significant differences between both groups (global longitudinal strainGLS -16.1% vs. -20.4%, P<0.0001; global circumferential strain -14.3 vs. -21.4%, P<0.0001), detecting 66% (global longitudinal strain) and 76% (global circumferential strain) of patients with pathologic values in contrast to 6% (EF) and 16% (FS) for standard parameters. Markers for disturbances of ECM remodeling (C-telopeptide for type I collagen, intact N-terminal propeptide of type III procollagen, each P<0.0001) and growth differentiation factor 15 (P<0.0001) were significantly different between the groups. CONCLUSION Strain imaging and new cardiac biomarkers used in HFpEF focusing on ECM remodeling appear to be more sensitive in detecting early remodeling processes in CCS than standard echo and laboratory parameters.
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Affiliation(s)
| | | | - Roland Weber
- Department of Paediatric Cardiology, Heart Center
| | | | | | - Eva Bergsträsser
- Department of Paediatric Oncology, University Children's Hospital, Zurich, Switzerland
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Desai VG, Vijay V, Han T, Moland CL, Phanavanh B, Lee T, Davis KJ, Muskhelishvili L, Stine KC, Fuscoe JC. Doxorubicin-induced delayed-onset subclinical cardiotoxicity in mice. J Appl Toxicol 2021; 42:778-792. [PMID: 34668590 DOI: 10.1002/jat.4256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 12/22/2022]
Abstract
Subclinical cardiotoxicity at low total cumulative doxorubicin (DOX) doses can manifest into cardiomyopathy in long-term cancer survivors. However, the underlying mechanisms are poorly understood. In male B6C3F1 mice, assessment of cardiac function by echocardiography was performed at 1, 4, 10, 17, and 24 weeks after exposure to 6, 9, 12, and 24 mg/kg total cumulative DOX doses or saline (SAL) to monitor development of delayed-onset cardiotoxicity. The 6- or 9-mg/kg total cumulative doses resulted in a significant time-dependent decline in systolic function (left ventricular ejection fraction (LVEF) and fractional shortening (FS)) during the 24-week recovery although there was not a significant alteration in % LVEF or % FS at any specific time point during the recovery. A significant decline in systolic function was elicited by the cardiotoxic cumulative DOX dose (24 mg/kg) during the 4- to 24-week period after treatment compared to SAL-treated counterparts. At 24 weeks after DOX treatment, a significant dose-related decrease in the expression of genes and proteins involved in sarcoplasmic reticulum (SR) calcium homeostasis (Ryr2 and Serca2) was associated with a dose-related increase in the transcript level of Casp12 (SR-specific apoptosis) in hearts. These mice also showed enhanced apoptotic activity in hearts indicated by a significant dose-related elevation in the number of apoptotic cardiomyocytes compared to SAL-treated counterparts. These findings collectively suggest that a steady decline in SR calcium handling and apoptosis might be involved in the development of subclinical cardiotoxicity that can evolve into irreversible cardiomyopathy later in life.
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Affiliation(s)
- Varsha G Desai
- Personalized Medicine Branch, Division of Systems Biology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - Vikrant Vijay
- Personalized Medicine Branch, Division of Systems Biology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - Tao Han
- Personalized Medicine Branch, Division of Systems Biology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - Carrie L Moland
- Personalized Medicine Branch, Division of Systems Biology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - Bounleut Phanavanh
- Personalized Medicine Branch, Division of Systems Biology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - Taewon Lee
- Division of Applied Mathematical Sciences, Korea University, Sejong, South Korea
| | - Kelly J Davis
- Toxicologic Pathology Associates, National Center for Toxicological Research, Jefferson, Arkansas, USA
| | - Levan Muskhelishvili
- Toxicologic Pathology Associates, National Center for Toxicological Research, Jefferson, Arkansas, USA
| | - Kimo C Stine
- Department of Pediatrics, Pediatric Hematology-Oncology, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - James C Fuscoe
- Personalized Medicine Branch, Division of Systems Biology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
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Ehrhardt MJ. Progress Toward Improving Recommended Screening Practices in Survivors of Childhood Cancer at Risk for Cardiomyopathy. JACC CardioOncol 2021; 3:73-75. [PMID: 34396307 PMCID: PMC8352024 DOI: 10.1016/j.jaccao.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Matthew J. Ehrhardt
- Department of Oncology and Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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10
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Shaheen N, Jan MRU, Riaz S, Khan MS. Late Morbidity among Survivors of Childhood Cancers; Experience at Tertiary Care Cancer Hospital. JOURNAL OF CANCER & ALLIED SPECIALTIES 2020; 6:e351. [PMID: 37197606 PMCID: PMC10166322 DOI: 10.37029/jcas.v6i2.351] [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: 03/02/2020] [Accepted: 05/12/2020] [Indexed: 05/19/2023]
Abstract
Background Long-term survivors of childhood malignancies are at increased risk of experiencing treatment-related morbidities. Survival into late adulthood in these children provides ample time for the acquisition of long-term sequelae. This study aimed to determine the late adverse effects among long-term survivors of childhood cancer from a low-income country perspective. Materials and Methods Data were retrospectively collected from review of charts of patients aged under 18 years at the time of their primary diagnosis between 1 January, 1995, and 31 December, 2008, and who survived for at least 5 years after completion of their treatment. Analysed data included demographics, cancer type, treatment modality, types of chemotherapy agents administered and specific late morbidities including frequency of azoospermia, oligospermia, endocrine abnormalities, hearing and pulmonary function impairment and cardiac dysfunction among the long-term survivors of cancer. Results The total number of patients was 300 with a mean age of 18 ± 2 years. The male to female ratio was 2.7:1. Median follow-up duration was 18 years (range: 5-25 years). Seventy-seven percent of patients were from Punjab, 20% were from Khyber Pakhtunkhwa and 3% were from other provinces. Fifty percent had a diagnosis of Hodgkin lymphoma, 17% had acute lymphoblastic leukaemia, 13% had non-Hodgkin lymphoma, 10% had germ cell tumours and 10% had other tumours. Fifty-seven percent received chemotherapy, 23% had chemotherapy and radiotherapy, 15% had chemotherapy and surgery, 3% had chemotherapy, surgery and radiotherapy and 2% had only surgery. Notable long-term documented sequelae were; azoospermia/oligospermia in 64%, endocrine abnormalities in 25% with hypothyroidism in 13.5% and follicle-stimulating hormone and luteinizing hormone abnormalities in 11.5%, ototoxicity in 6.5%, impaired pulmonary function tests in 4.6%, cardiotoxicity in 2.4% and second malignancies (acute myeloid leukaemia and myelodysplastic syndrome) in 1%. Conclusion Childhood cancer survivors are at increased risk of adverse treatment-related sequelae and a long-term follow-up plan should be in place in centres where they receive treatment for their primary disease.
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Affiliation(s)
- Najma Shaheen
- Department of Pediatric Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Mir Rooh Ullah Jan
- Department of Pediatric Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Shazia Riaz
- Department of Pediatric Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Muhammad Saghir Khan
- Department of Pediatric Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
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McDonald JP, MacNamara JP, Zaha VG. Challenges in Implementing Optimal Echocardiographic Screening in Cardio-Oncology. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:39. [DOI: 10.1007/s11936-019-0740-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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12
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Treatment exposures stratify need for echocardiographic screening in asymptomatic long-term survivors of hematopoietic stem cell transplantation. Cardiol Young 2019; 29:338-343. [PMID: 30744727 DOI: 10.1017/s104795111800238x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We sought to define the prevalence of echocardiographic abnormalities in long-term survivors of paediatric hematopoietic stem cell transplantation and determine the utility of screening in asymptomatic patients. We analysed echocardiograms performed on survivors who underwent hematopoietic stem cell transplantation from 1982 to 2006. A total of 389 patients were alive in 2017, with 114 having an echocardiogram obtained ⩾5 years post-infusion. A total of 95 patients had echocardiogram performed for routine surveillance. The mean time post-hematopoietic stem cell transplantation was 13 years. Of 95 patients, 77 (82.1%) had ejection fraction measured, and 10/77 (13.0%) had ejection fraction z-scores ⩽-2.0, which is abnormally low. Those patients with abnormal ejection fraction were significantly more likely to have been exposed to anthracyclines or total body irradiation. Among individuals who received neither anthracyclines nor total body irradiation, only 1/31 (3.2%) was found to have an abnormal ejection fraction of 51.4%, z-score -2.73. In the cohort of 77 patients, the negative predictive value of having a normal ejection fraction given no exposure to total body irradiation or anthracyclines was 96.7% at 95% confidence interval (83.3-99.8%). Systolic dysfunction is relatively common in long-term survivors of paediatric hematopoietic stem cell transplantation who have received anthracyclines or total body irradiation. Survivors who are asymptomatic and did not receive radiation or anthracyclines likely do not require surveillance echocardiograms, unless otherwise indicated.
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Utility of Echocardiography as Screening for Late-onset Anthracycline-induced Cardiotoxicity in Pediatric Cancer Survivors: Observations from the First Decade After End of Therapy. J Pediatr Hematol Oncol 2018; 40:e283-e288. [PMID: 29432303 DOI: 10.1097/mph.0000000000001087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Current screening guidelines are available for anthracycline-induced cardiotoxicity. However, the utility of echocardiogram screening for late-onset anthracycline cardiotoxicity especially in the decade immediately after end of therapy is debatable. A retrospective chart review of patients seen in the Thriving after Cancer Clinic at Rady Children's Hospital January 2006 to December 2013 was performed. Treatment data, echocardiogram results, cardiology referral notes and cardiac medication data were abstracted from anthracycline-exposed survivors. Descriptive and univariate comparative statistics were performed. Of 368 patients (45% female, median 5.3 y old at diagnosis [range 0 to 18.3], median 5.0 y from end of therapy [EOT] [range 0 to 18.2]), a total of 4 patients (10-year cumulative incidence after EOT 1.3%; 95% confidence interval, 0.1%-19.7%) required cardiac medication for late-onset cardiotoxicity (>1 y after EOT). Those requiring medication for late-onset cardiotoxicity were exposed to more anthracyclines than survivors without cardiotoxicity (median, 360 mg/m [range, 300 to 375 mg/m] vs. 182 mg/m [range, 26 to 515 mg/m], P=0.009). None had neck or chest radiation. In this population, medication initiation for late-onset anthracycline cardiotoxicity was limited predominantly to the first 3 years after EOT, with the next >13 years after EOT. These findings add to the growing body of literature assessing current guidelines to inform improvements in screening practices of survivorship providers.
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14
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Echocardiographic evolution of left ventricular function in childhood leukemia survivors. Curr Probl Cancer 2018; 42:397-408. [DOI: 10.1016/j.currproblcancer.2018.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/11/2018] [Accepted: 07/20/2018] [Indexed: 11/23/2022]
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Markman TM, Ruble K, Loeb D, Chen A, Zhang Y, Beasley GS, Thompson WR, Nazarian S. Electrophysiological effects of anthracyclines in adult survivors of pediatric malignancy. Pediatr Blood Cancer 2017; 64. [PMID: 28453898 DOI: 10.1002/pbc.26556] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 02/25/2017] [Accepted: 02/27/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anthracycline use is limited by cardiotoxicity, including arrhythmias and left ventricular (LV) dysfunction. We aim to characterize the association between electrophysiological changes and LV dysfunction. METHODS A retrospective chart review was conducted, including all 147 pediatric cancer survivors at our institution over 18 years of age and treated with an anthracycline. One hundred thirty-four patients who had at least one electrocardiogram (ECG) and echocardiogram were analyzed. The association between dysfunction and baseline characteristics, treatment history, and electrocardigraphic parameters were analyzed using multivariable logistic regression. Additionally, a longitudinal generalized estimating equation (GEE) model was used to examine the temporal association between repeated measure corrected QT (QTc) intervals and subsequent LV function. RESULTS In our population, 24% of patients had LV dysfunction. The initial posttreatment QTc interval was longer in patients with LV dysfunction (438 ± 35 vs. 420 ± 20 msec, P = 0.002). In logistic regression analysis, QTc interval (P < 0.001) and cumulative radiation dose (P = 0.027) were associated with LV dysfunction. On ECGs performed prior to evidence of LV dysfunction, the QTc was longer than on ECGs preceding a normal echocardiogram (451 ± 32 msec vs. 423 ± 25 msec, P < 0.001). Mean time from QTc ≥ 450 msec to evidence of LV dysfunction was 1.8 ± 2.9 years. In the longitudinal GEE model, QTc prolongation was associated with subsequent decreased fractional shortening. CONCLUSIONS Among adult survivors of pediatric cancer treated with anthracyclines, prolongation of the QTc interval was associated with subsequent LV dysfunction.
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Affiliation(s)
- Timothy M Markman
- Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Kathryn Ruble
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland.,Division of Pediatric Oncology, The Johns Hopkins University, Baltimore, Maryland
| | - David Loeb
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland.,Division of Pediatric Oncology, The Johns Hopkins University, Baltimore, Maryland
| | - Allen Chen
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland.,Division of Pediatric Oncology, The Johns Hopkins University, Baltimore, Maryland
| | - Yiyi Zhang
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gary S Beasley
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland.,Division of Pediatric Cardiology, The Johns Hopkins University, Baltimore, Maryland
| | - W Reid Thompson
- Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland.,Division of Pediatric Cardiology, The Johns Hopkins University, Baltimore, Maryland
| | - Saman Nazarian
- Department of Medicine, The Johns Hopkins University, Baltimore, Maryland.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Division of Cardiology, Section for Cardiac Electrophysiology, The Johns Hopkins University, Baltimore, Maryland.,Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Spewak MB, Williamson RS, Mertens AC, Border WL, Meacham LR, Wasilewski-Masker KJ. Yield of screening echocardiograms during pediatric follow-up in survivors treated with anthracyclines and cardiotoxic radiation. Pediatr Blood Cancer 2017; 64. [PMID: 27966803 DOI: 10.1002/pbc.26367] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Guidelines published by the Children's Oncology Group recommend screening echocardiograms for childhood cancer survivors exposed to anthracyclines and/or cardiotoxic radiation. This study aims to assess risk factors for cardiac late effects while evaluating the overall yield of screening echocardiograms. PROCEDURE Demographics, exposures, and echocardiogram results were abstracted from the medical records of survivors diagnosed at ≤ 21 years old and ≥ 2 years off therapy who were exposed to anthracyclines and/or potentially cardiotoxic radiotherapy. Descriptive statistics and logistic regressions were performed and the yield of screening echocardiograms was calculated. RESULTS Of 853 patients, 1,728 screening echocardiograms were performed, and 37 patients had an abnormal echocardiogram (overall yield 2.1%). Yields were only somewhat higher in more frequently screened patients. Risk factors for an abnormal result included anthracycline dose of ≥300 mg/m2 (adjusted odds ratio [aOR] 3.1; 95% confidence interval [CI]: 1.3-7.2; P < 0.01) with a synergist relationship in patients who also received radiation doses ≥30 Gy (aOR 7.0; 95% CI: 1.6-31.9; P = 0.01), as well as autologous bone marrow transplant (OR 3.3; 95% CI: 1.3-8.5; P = 0.01). Sex, race, age at diagnosis, and cyclophosphamide exposure were not statistically significant risk factors, and no patient receiving <100 mg/m2 anthracycline dose without concomitant radiation had an abnormal echocardiogram. CONCLUSIONS Dose-dependent and synergist anthracycline and cardiotoxic radiotherapy risks for developing cardiomyopathy were confirmed. However, previously identified risk factors including female sex, black race, and early age at diagnosis were not replicated in this cohort. The yields showed weak correlation across frequency categories. Echocardiographic screening recommendations for low-risk pediatric patients may warrant re-evaluation.
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Affiliation(s)
- Michael B Spewak
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Rebecca S Williamson
- The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ann C Mertens
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - William L Border
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lillian R Meacham
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Karen J Wasilewski-Masker
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
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17
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Erratum: Correction to Ramjaun A, AlDuhaiby E, Ahmed S, et al. Pediatr Blood Cancer 2017; 64:e26352. [PMID: 28112498 PMCID: PMC6885988 DOI: 10.1002/pbc.26352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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18
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Echocardiography and Alternative Cardiac Imaging Strategies for Long-Term Cardiotoxicity Surveillance of Cancer Survivors Treated with Chemotherapy and/or Radiation Exposure. Curr Oncol Rep 2016; 18:52. [DOI: 10.1007/s11912-016-0532-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Amini A, Murphy B, Cost CR, Garrington TP, Greffe BS, Liu AK. Cardiac Mortality in Children and Adolescents with Hodgkin's Lymphoma: A Surveillance, Epidemiology and End Results Analysis. J Adolesc Young Adult Oncol 2016; 5:181-6. [PMID: 26959398 DOI: 10.1089/jayao.2015.0067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The purpose of this study was to evaluate the risk of cardiac death in pediatric Hodgkin's lymphoma (HL) survivors and identify high-risk groups that may need additional surveillance. METHODS The Surveillance, Epidemiology and End Results program database was queried to analyze the rates of radiation therapy (RT) use and cardiac-specific mortality (CSM) in HL patients, aged 0-21 years, treated from 1973 to 2007. Primary endpoint was cardiac mortality. RESULTS A total of 6552 patients were included. Median follow-up was 12 years (range, 0-40). Median age at diagnosis was 17 years (range, 0-21). The majority were white (85.5%), from western states (41.2%), had nodular sclerosis HL (73.2%), presented with stage I or II disease (51.5%), and received RT (56.1%). Death from cardiac disease occurred in 114 patients (9.2% of all deaths). CSM for the entire cohort at 10-, 20-, and 30-year time points was 0.3%, 1.6%, and 5.0%, respectively. Median age at the time of cardiac death was 39 years (range, 18-58 years). Under multivariate analysis (MVA), adolescent patients (ages 13-21) had higher rates of CSM (hazard ratio [HR], 3.05; p = 0.005). Female gender (HR, 0.43; p < 0.001), patients treated from 1998 to 2007 (HR, 0.19; p = 0.018), and those with lymphocyte-rich histology (HR, 0.14; p = 0.047) had significantly lower rates of CSM. Use of RT was not associated with CSM under MVA (HR, 1.18, p = 0.452). CONCLUSION The cumulative incidence of CSM in this population analysis of pediatric HL was 9.2%, with a steady decline over the past several decades. Adolescent patients at diagnosis and males were more likely to die of cardiac-related causes.
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Affiliation(s)
- Arya Amini
- 1 Department of Radiation Oncology, University of Colorado School of Medicine , Aurora, Colorado
| | - Blair Murphy
- 1 Department of Radiation Oncology, University of Colorado School of Medicine , Aurora, Colorado.,2 Department of Radiation Oncology, Oregon Health and Science University , Portland, Oregon
| | - Carrye R Cost
- 3 Department of Pediatrics, Division of Hematology and Oncology, University of Colorado School of Medicine , Aurora, Colorado
| | - Timothy P Garrington
- 3 Department of Pediatrics, Division of Hematology and Oncology, University of Colorado School of Medicine , Aurora, Colorado
| | - Brian S Greffe
- 3 Department of Pediatrics, Division of Hematology and Oncology, University of Colorado School of Medicine , Aurora, Colorado
| | - Arthur K Liu
- 1 Department of Radiation Oncology, University of Colorado School of Medicine , Aurora, Colorado
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Ehrhardt MJ, Fulbright JM, Armenian SH. Cardiomyopathy in Childhood Cancer Survivors: Lessons from the Past and Challenges for the Future. Curr Oncol Rep 2016; 18:22. [DOI: 10.1007/s11912-016-0510-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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21
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Armenian SH, Wong FL. Screening for Anthracycline-Related Cardiac Dysfunction in Childhood Cancer Survivors: Can Less be More? Pediatr Blood Cancer 2015; 62:2067-8. [PMID: 26230357 DOI: 10.1002/pbc.25693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 01/16/2023]
Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, California
| | - F Lennie Wong
- Department of Population Sciences, City of Hope, Duarte, California
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Affiliation(s)
- Petra Rocic
- Department of Pharmacology, New York Medical College, Valhalla, New York
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