1
|
Gao Y, Zhang H, Qiu Y, Bian X, Wang X, Li Y. Early identification of severe immune checkpoint inhibitor associated myocarditis: From an electrocardiographic perspective. Cancer Med 2024; 13:e7460. [PMID: 39082198 PMCID: PMC11289619 DOI: 10.1002/cam4.7460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/28/2024] [Accepted: 06/24/2024] [Indexed: 08/02/2024] Open
Abstract
OBJECTIVES Immune checkpoint inhibitor (ICI)-associated myocarditis, particularly severe ICI-associated myocarditis, has a high mortality rate. However, the predictive value of electrocardiogram (ECG) remains unclear. The present study aimed to evaluate the predictive value of clinical and electrocardiographic parameters for severe myocarditis. METHODS Clinical and electrocardiographic data of 73 cancer patients with ICI-associated myocarditis were retrospectively collected. The severity of ICI-associated myocarditis was graded using the NCCN guidelines for managing immunotherapy-related toxicities. Myocarditis grades 1-2 and grades 3-4 were classified as mild and severe myocarditis, respectively. Logistic regression analysis was performed to analyze the predictive value of each parameter in predicting severe myocarditis. RESULTS Among the 73 patients with myocarditis, 20 (27.4%) patients had severe myocarditis. Compared with mild myocarditis group, sinus tachycardia (p = 0.001), QRS duration ≥110 ms (p = 0.001), prolonged QTc interval (p < 0.001), and bundle branch block (p = 0.007) at the time of myocarditis were more common in the severe myocarditis group. Logistic regression analysis revealed that sinus tachycardia (p = 0.028) and QTc interval prolongation (p = 0.007) were predictors of severe myocarditis. Whereas the predictive value of other electrocardiographic parameters was weak. Concurrent targeted therapy didn't increase the risk of severe myocarditis. A high NT-proBNP level was associated with severe myocarditis. CONCLUSIONS ECG at the onset of myocarditis manifested as sinus tachycardia and prolonged QTc interval predicted a high risk of severe myocarditis. Early detection of ECG abnormalities may faciliate early detection of severe ICI-associated myocarditis.
Collapse
Affiliation(s)
- Yongyin Gao
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Hongdian Zhang
- Department of Esophageal CancerTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Key Laboratory of Digestive Cancer of Tianjin, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Yanli Qiu
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Xueyan Bian
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Xue Wang
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Yue Li
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
| |
Collapse
|
2
|
Ciccarese C, Anghelone A, Stefani A, Cigliola A, Strusi A, D'Agostino F, Bria E, Iacovelli R, Tortora G. The incidence and relative risk of major adverse cardiovascular events and hypertension in patients treated with immune checkpoint inhibitors plus tyrosine-kinase inhibitors for solid tumors: a systemic review and meta-analysis. Expert Rev Anticancer Ther 2024; 24:623-633. [PMID: 38879826 DOI: 10.1080/14737140.2024.2357814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/03/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Combinations of immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) can be responsible for major adverse cardiovascular events (MACEs). We performed a meta-analysis to assess the relative risk (RR) of MACEs and hypertension in cancer patients treated with ICI+TKI combinations. RESEARCH DESIGN AND METHODS We selected prospective trials through MEDLINE/PubMed, Cochrane Library, and ASCOMeeting abstracts. We calculated combined ORs, RRs, and 95% CIs using RevMansoftware for meta-analysis (v.5.2.3). RESULTS Seven studies were selected for the analysis of MACEs (3849 patients). The incidence MACEs were 0.8% with ICI+TKI combinations, compared to 0.2% in the control arms for both any- and high-grade. ICI+TKI combinations significantly increased the risk of any- (OR = 3.21; p = 0.01) and high-grade MACEs (OR = 2.72; p = 0.05). Ten studies were selected for the analysis of hypertension (5744 patients). The incidence of treatment-related hypertension of any-grade and high-grade was41.3% (vs. 20.8%) and 26.1% (vs. 12.3%) with ICI+TKI combinations, respectively. ICI+TKI combinations significantly increased the risk of treatment-related hypertension of any-grade (RR = 2.10; p = 0.001), but not of high-grade (p = 0.11). CONCLUSIONS ICI+TKI combinations increase the risk of MACEs compared to controls, although the absolute incidence is eventually low. Routine cardiovascular monitoring in asymptomatic patients is therefore not recommended.
Collapse
Affiliation(s)
- Chiara Ciccarese
- Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Alessio Stefani
- Medical Oncology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Cigliola
- Medical Oncology, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Emilio Bria
- Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Medical Oncology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto Iacovelli
- Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Medical Oncology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giampaolo Tortora
- Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Medical Oncology, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
3
|
Chen YH, Kovács T, Ferdinandy P, Varga ZV. Treatment options for immune-related adverse events associated with immune checkpoint inhibitors. Br J Pharmacol 2024. [PMID: 38803135 DOI: 10.1111/bph.16405] [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: 12/01/2023] [Revised: 02/14/2024] [Accepted: 03/09/2024] [Indexed: 05/29/2024] Open
Abstract
The immunotherapy revolution with the use of immune checkpoint inhibitors (ICIs) started with the clinical use of the first ICI, ipilimumab, in 2011. Since then, the field of ICI therapy has rapidly expanded - with the FDA approval of 10 different ICI drugs so far and their incorporation into the therapeutic regimens of a range of malignancies. While ICIs have shown high anti-cancer efficacy, they also have characteristic side effects, termed immune-related adverse events (irAEs). These side effects hinder the therapeutic potential of ICIs and, therefore, finding ways to prevent and treat them is of paramount importance. The current protocols to manage irAEs follow an empirical route of steroid administration and, in more severe cases, ICI withdrawal. However, this approach is not optimal in many cases, as there are often steroid-refractory irAEs, and there is a potential for corticosteroid use to promote tumour progression. This review surveys the current alternative approaches to the treatments for irAEs, with the goal of summarizing and highlighting the best attempts to treat irAEs, without compromising anti-tumour immunity and allowing for rechallenge with ICIs after resolution of the irAEs.
Collapse
Affiliation(s)
- Yu Hua Chen
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Tamás Kovács
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Zoltán V Varga
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| |
Collapse
|
4
|
Jiang J, Shu H, Wang DW, Hui R, Li C, Ran X, Wang H, Zhang J, Nie S, Cui G, Xiang D, Shao Q, Xu S, Zhou N, Li Y, Gao W, Chen Y, Bian Y, Wang G, Xia L, Wang Y, Zhao C, Zhang Z, Zhao Y, Wang J, Chen S, Jiang H, Chen J, Du X, Chen M, Sun Y, Li S, Ding H, Ma X, Zeng H, Lin L, Zhou S, Ma L, Tao L, Chen J, Zhou Y, Guo X. Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis. SCIENCE CHINA. LIFE SCIENCES 2024; 67:913-939. [PMID: 38332216 DOI: 10.1007/s11427-023-2421-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/25/2023] [Indexed: 02/10/2024]
Abstract
Fulminant myocarditis is an acute diffuse inflammatory disease of myocardium. It is characterized by acute onset, rapid progress and high risk of death. Its pathogenesis involves excessive immune activation of the innate immune system and formation of inflammatory storm. According to China's practical experience, the adoption of the "life support-based comprehensive treatment regimen" (with mechanical circulation support and immunomodulation therapy as the core) can significantly improve the survival rate and long-term prognosis. Special emphasis is placed on very early identification,very early diagnosis,very early prediction and very early treatment.
Collapse
Affiliation(s)
- Jiangang Jiang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hongyang Shu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dao Wen Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Rutai Hui
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Chenze Li
- Zhongnan Hospital of Wuhan University, Wuhan, 430062, China
| | - Xiao Ran
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hong Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jing Zhang
- Fuwai Huazhong Cardiovascular Hospital, Zhengzhou, 450003, China
| | - Shaoping Nie
- Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Guanglin Cui
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dingcheng Xiang
- Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Qun Shao
- Harbin Medical University Cancer Hospital, Harbin, 150081, China
| | - Shengyong Xu
- Union Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ning Zhou
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yuming Li
- Taida Hospital, Tianjin, 300457, China
| | - Wei Gao
- Peking University Third Hospital, Beijing, 100191, China
| | - Yuguo Chen
- Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Yuan Bian
- Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Guoping Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Liming Xia
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yan Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chunxia Zhao
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhiren Zhang
- Harbin Medical University Cancer Hospital, Harbin, 150081, China
| | - Yuhua Zhao
- Kanghua Hospital, Dongguan, Guangzhou, 523080, China
| | - Jianan Wang
- Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Shaoliang Chen
- Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Hong Jiang
- Renmin Hospital of Wuhan University, Wuhan, 430060, Wuhan, China
| | - Jing Chen
- Renmin Hospital of Wuhan University, Wuhan, 430060, Wuhan, China
| | - Xianjin Du
- Renmin Hospital of Wuhan University, Wuhan, 430060, Wuhan, China
| | - Mao Chen
- West China Hospital, Sichuan University, Chengdu, 610044, China
| | - Yinxian Sun
- First Hospital of China Medical University, Shenyang, 110002, China
| | - Sheng Li
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hu Ding
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xueping Ma
- General Hospital of Ningxia Medical University, Yinchuan, 750003, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Li Lin
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shenghua Zhou
- The Second Xiangya Hospital, Central South University, Changsha, 410012, China
| | - Likun Ma
- The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230002, China
| | - Ling Tao
- The First Affiliated Hospital of Air Force Medical University, Xi'an, 710032, China
| | - Juan Chen
- Central Hospital of Wuhan City, Wuhan, 430014, China
| | - Yiwu Zhou
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaomei Guo
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| |
Collapse
|
5
|
Kreidieh F, McQuade J. Novel insights into cardiovascular toxicity of cancer targeted and immune therapies: Beyond ischemia with non-obstructive coronary arteries (INOCA). AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 40:100374. [PMID: 38510501 PMCID: PMC10946000 DOI: 10.1016/j.ahjo.2024.100374] [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: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
Novel immune and targeted therapies approved over the past 2 decades have resulted in dramatic improvements in cancer-specific outcomes for many cancer patients. However, many of these agents can induce cardiovascular toxicity in a subset of patients. The field of cardio-oncology was established based on observations that anti-neoplastic chemotherapies and mantle radiation can lead to premature cardiomyopathy in cancer survivors. While conventional chemotherapy, targeted therapy, and immune therapies can all result in cardiovascular adverse events, the mechanisms, timing, and incidence of these events are inherently different. Many of these effects converge upon the coronary microvasculature to involve, through endocardial endothelial cells, a more direct effect through close proximity to cardiomyocyte with cellular communication and signaling pathways. In this review, we will provide an overview of emerging paradigms in the field of Cardio-Oncology, particularly the role of the coronary microvasculature in mediating cardiovascular toxicity of important cancer targeted and immune therapies. As the number of cancer patients treated with novel immune and targeted therapies grows exponentially and subsequently the number of long-term cancer survivors dramatically increases, it is critical that cardiologists and cardiology researchers recognize the unique potential cardiovascular toxicities of these agents.
Collapse
Affiliation(s)
- Firas Kreidieh
- Instructor of Clinical Medicine- Division of Hematology-Oncology; Associate Director- Internal Medicine Residency Program, American University of Beirut, Beirut, Lebanon
| | - Jennifer McQuade
- Associate Professor and Physician Scientist in Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| |
Collapse
|
6
|
He Y, Yu H, Dai S, He M, Ma L, Xu Z, Luo F, Wang L. Immune checkpoint inhibitors break whose heart? Perspectives from cardio-immuno-oncology. Genes Dis 2024; 11:807-818. [PMID: 37692505 PMCID: PMC10491874 DOI: 10.1016/j.gendis.2023.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/12/2023] [Indexed: 03/30/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibody antagonists, which can block cytotoxic T lymphocyte antigen-4 (CTLA-4), programmed death-1/ligand-1 (PD-1/PD-L1) pathways, and other molecules exploited by tumor cells to evade T cell-mediated immune response. ICIs have transformed the treatment landscape for various cancers due to their amazing efficacy. Many anti-tumor therapies, including targeted therapy, radiotherapy, and chemotherapy, combine ICIs to make the treatment more effective. However, the off-target immune activation caused by ICIs may lead to a broad spectrum of immune-related adverse events (irAEs) affecting multiple organ systems. Among irAEs, cardiotoxicity induced by ICIs, uncommon but fatal, has greatly offset survival benefits from ICIs, which is heartbreaking for both patients and clinicians. Consequently, such cardiotoxicity requires special vigilance, and it has become a common challenge both for patients and clinicians. This article reviewed the clinical manifestations and influence of cardiotoxicity from the view of patients and clinicians, elaborated on the underlying mechanisms in conjunction with animal studies, and then attempted to propose management strategies from a cardio-immuno-oncology multidisciplinary perspective.
Collapse
Affiliation(s)
- Yingying He
- Oncology Department, Deyang People's Hospital, Deyang, Sichuan 618000, China
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Hui Yu
- Cardiovascular Department, Mianyang Central Hospital, Mianyang, Sichuan 621000, China
| | - Shuang Dai
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Miao He
- Oncology Department, Deyang People's Hospital, Deyang, Sichuan 618000, China
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Ling Ma
- Department of Rheumatology and Immunology, Deyang People's Hospital, Deyang, Sichuan 618000, China
| | - Zihan Xu
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Feng Luo
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Li Wang
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| |
Collapse
|
7
|
de Jesus M, Chanda A, Grabauskas T, Kumar M, Kim AS. Cardiovascular disease and lung cancer. Front Oncol 2024; 14:1258991. [PMID: 38410099 PMCID: PMC10896114 DOI: 10.3389/fonc.2024.1258991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/19/2024] [Indexed: 02/28/2024] Open
Abstract
Lung cancer is the second most common cancer worldwide and the leading cause of cancer-related death. While survival rates have improved with advancements in cancer therapeutics, additional health challenges have surfaced. Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in patients with lung cancer. CVD and lung cancer share many risk factors, such as smoking, hypertension, diabetes, advanced age, and obesity. Optimal management of this patient population requires a full understanding of the potential cardiovascular (CV) complications of lung cancer treatment. This review outlines the common shared risk factors, the spectrum of cardiotoxicities associated with lung cancer therapeutics, and prevention and management of short- and long-term CVD in patients with non-small cell (NSCLC) and small cell (SCLC) lung cancer. Due to the medical complexity of these patients, multidisciplinary collaborative care among oncologists, cardiologists, primary care physicians, and other providers is essential.
Collapse
Affiliation(s)
- Mikhail de Jesus
- Department of Cardiology, University of Connecticut Hartford Hospital, Hartford, CT, United States
| | - Anindita Chanda
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, United States
| | - Titas Grabauskas
- University of Connecticut School of Medicine, Farmington, CT, United States
| | - Manish Kumar
- Department of Cardiology, Pat & Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, United States
| | - Agnes S Kim
- Department of Cardiology, Pat & Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, United States
| |
Collapse
|
8
|
Shalata W, Steckbeck R, Abu Salman A, Abu Saleh O, Abu Jama A, Attal ZG, Shalata S, Alnsasra H, Yakobson A. Perimyocarditis Associated with Immune Checkpoint Inhibitors: A Case Report and Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:224. [PMID: 38399513 PMCID: PMC10890382 DOI: 10.3390/medicina60020224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Patient prognoses have been significantly enhanced by immune checkpoint inhibitors (ICIs), altering the standard of care in cancer treatment. These novel antibodies have become a mainstay of care for metastatic non-small-cell lung cancer (mNSCLC) patients. Several types of adverse events related to ICIs have been identified and documented as a result of the launch of these innovative medicines. We present here a 74-year-old female patient with a stage IV lung adenocarcinoma, treated with nivolumab plus ipilimumab, who developed perimyocarditis two weeks after receiving the third cycle of immune checkpoint inhibitor therapy. The patient was diagnosed using troponin levels, computed tomography (CT) angiography, and echocardiography. After hospitalization, her cardiac condition was successfully resolved with corticosteroids, colchicine, and symptomatic treatment. To the best of our knowledge, this is one of the rarest cases to be reported of perimyocarditis as a toxicity of immunotherapy in a patient treated for adenocarcinoma of the lung.
Collapse
Affiliation(s)
- Walid Shalata
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Rachel Steckbeck
- Medical School for International Health and Sciences, Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Amjad Abu Salman
- Cardiology Department, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Omar Abu Saleh
- Department of Dermatology and Venereology, Emek Medical Centre, Afula 18341, Israel
| | - Ashraf Abu Jama
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Zoé Gabrielle Attal
- Medical School for International Health and Sciences, Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Sondos Shalata
- Nutrition Unit, Galilee Medical Center, Nahariya 22000, Israel
| | - Hilmi Alnsasra
- Cardiology Department, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Alexander Yakobson
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| |
Collapse
|
9
|
Crisci G, Bobbio E, Gentile P, Bromage DI, Bollano E, Ferone E, Israr MZ, Heaney LM, Polte CL, Cannatà A, Salzano A. Biomarkers in Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Updated Review of the Literature. J Clin Med 2023; 12:7214. [PMID: 38068265 PMCID: PMC10706911 DOI: 10.3390/jcm12237214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/10/2023] [Accepted: 11/17/2023] [Indexed: 02/15/2024] Open
Abstract
Myocarditis is a disease caused by cardiac inflammation that can progress to dilated cardiomyopathy, heart failure, and eventually death. Several etiologies, including autoimmune, drug-induced, and infectious, lead to inflammation, which causes damage to the myocardium, followed by remodeling and fibrosis. Although there has been an increasing understanding of pathophysiology, early and accurate diagnosis, and effective treatment remain challenging due to the high heterogeneity. As a result, many patients have poor prognosis, with those surviving at risk of long-term sequelae. Current diagnostic methods, including imaging and endomyocardial biopsy, are, at times, expensive, invasive, and not always performed early enough to affect disease progression. Therefore, the identification of accurate, cost-effective, and prognostically informative biomarkers is critical for screening and treatment. The review then focuses on the biomarkers currently associated with these conditions, which have been extensively studied via blood tests and imaging techniques. The information within this review was retrieved through extensive literature research conducted on major publicly accessible databases and has been collated and revised by an international panel of experts. The biomarkers discussed in the article have shown great promise in clinical research studies and provide clinicians with essential tools for early diagnosis and improved outcomes.
Collapse
Affiliation(s)
- Giulia Crisci
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy;
- Italian Clinical Outcome Research and Reporting Program (I-CORRP), 80131 Naples, Italy
| | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden; (E.B.); (E.B.)
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, 41390 Gothenburg, Sweden;
| | - Piero Gentile
- De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy;
| | - Daniel I. Bromage
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK; (D.I.B.); (E.F.)
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 8AF, UK
| | - Entela Bollano
- Department of Cardiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden; (E.B.); (E.B.)
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, 41390 Gothenburg, Sweden;
| | - Emma Ferone
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK; (D.I.B.); (E.F.)
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 8AF, UK
| | - Muhammad Zubair Israr
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK;
| | - Liam M. Heaney
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK;
| | - Christian L. Polte
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, 41390 Gothenburg, Sweden;
- Department of Clinical Physiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
| | - Antonio Cannatà
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK; (D.I.B.); (E.F.)
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 8AF, UK
| | - Andrea Salzano
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK;
- Cardiology Unit, AORN A Cardarelli, 80131 Naples, Italy
| |
Collapse
|
10
|
Banerjee A, Narasimhulu CA, Singla DK. Immune interactions in pembrolizumab (PD-1 inhibitor) cancer therapy and cardiovascular complications. Am J Physiol Heart Circ Physiol 2023; 325:H751-H767. [PMID: 37594487 PMCID: PMC10659324 DOI: 10.1152/ajpheart.00378.2023] [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: 06/26/2023] [Revised: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
The use of immunotherapies like pembrolizumab (PEM) is increasingly common for the management of numerous cancer types. The use of PEM to bolster T-cell response against tumor growth is well documented. However, the interactions PEM has on other immune cells to facilitate tumor regression and clearance is unknown and warrants further investigation. In this review, we present literature findings that have reported the interactions of PEM in stimulating innate and adaptive immune cells, which enhance cytotoxic phenotypes. This triggers secretion of cytokines and chemokines, which have both beneficial and detrimental effects. We also describe how this leads to the development of rare but underreported occurrence of PEM-induced immune-related cardiovascular complications that arise suddenly and progress rapidly to debilitating and fatal consequences. This review encourages further research and investigation of PEM-induced cardiovascular complications and other immune cell interactions in patients with cancer. As PEM therapy in treating cancer types is expanding, we expect that this review will inform health care professionals of diverse specializations of medicine like dermatology (melanoma skin cancers), ophthalmology (eye cancers), and pathology (hematological malignancies) about PEM-induced cardiac complications.
Collapse
Affiliation(s)
- Abha Banerjee
- Division of Metabolic and Cardiovascular Sciences, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, United States
| | - Chandrakala Aluganti Narasimhulu
- Division of Metabolic and Cardiovascular Sciences, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, United States
| | - Dinender K Singla
- Division of Metabolic and Cardiovascular Sciences, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, United States
| |
Collapse
|
11
|
Tamura Y, Tamura Y. Usefulness of Longitudinal Strain to Assess Cancer Therapy-Related Cardiac Dysfunction and Immune Checkpoint Inhibitor-Induced Myocarditis. Pharmaceuticals (Basel) 2023; 16:1297. [PMID: 37765105 PMCID: PMC10535915 DOI: 10.3390/ph16091297] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/08/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Longitudinal strain (LS) measured by echocardiography has been reported to be useful not only for the diagnosis and risk stratification of various cardiac diseases, but also in cardio-oncology. Most previous studies have been conducted on patients undergoing treatment with anthracyclines and human epidermal growth factor receptor 2-targeted therapies. Existing guidelines recommend that global LS (GLS) should be measured before and after the administration of cancer drugs. This recommendation is based on many reports showing that a decline in GLS is indicative of early or mild cancer therapy-related cardiac dysfunction. The main purpose of this article is to provide insight into the importance of LS in patients undergoing cancer treatment and highlight the role of LS evaluation in patients undergoing immune checkpoint inhibitor (ICI) treatment, which is being used with increasing frequency. Among cancer drug therapies, immune checkpoint inhibitors (ICIs) have an important place in cancer treatment and are used for the treatment of many types of cancer. Although the efficacy of ICIs in cancer treatment has been reported, immune-related adverse events (irAEs) have also been reported. Among these irAEs, cardiovascular complications, although rare, are recognized as important adverse events that may result in ICI treatment discontinuation. Myocarditis is one severe adverse event associated with ICIs, and it is important to standardize diagnostic and therapeutic approaches to it. Several studies have reported a relationship between LS and cardiac complications associated with ICIs which may contribute to the early diagnosis of ICI-induced cardiac complications.
Collapse
Affiliation(s)
- Yudai Tamura
- Cardiovascular Center, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan;
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita 286-8686, Japan
| | - Yuichi Tamura
- Cardiovascular Center, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan;
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita 286-8686, Japan
| |
Collapse
|
12
|
Moradi A, Kodali A, Okoye C, Klein DH, Mohamoud I, Olanisa OO, Parab P, Chaudhary P, Mukhtar S, Mohammed L. A Systematic Review of Myocarditis Induced by Immune Checkpoint Inhibitors: How Concerning Is the Most Common Cardiotoxicity of Immune Checkpoint Inhibitors? Cureus 2023; 15:e42071. [PMID: 37602125 PMCID: PMC10434730 DOI: 10.7759/cureus.42071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Novel cancer therapies have revolutionized the management of various cancers. An immune checkpoint inhibitor (ICI) is one of these antitumor medications. ICIs, which are immune therapies, enhance the immune system's capacity to fight cancer cells. Based on the receptors that they inhibit, such as PD-1, PD-L1, and CTLA-4, ICIs are subdivided. Although this class of drugs is extremely beneficial for cancer patients, their adverse effects can be fatal. Multiple organs, such as the cardiovascular system, may be impacted by immune-related adverse effects (irAEs). These cardiotoxic irAEs can occur at a rate of up to 1% and can be fatal. Myocarditis is the most prevalent of all cardiotoxicities. The purpose of this systematic review is to assess the seriousness of myocarditis, the most prevalent cardiotoxicity of ICIs, and the importance of screening. We chose studies based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria. Therefore, from 2018 to 2023, we gathered articles from databases such as PubMed, ScienceDirect, Web of Science, the Cochrane Library, and Google Scholar. Of the 665 studies identified based on various screening methods and quality assessment tools, 13 were selected for inclusion in the study. This study shows that although the risk of myocarditis in ICI therapy is low and the majority of cases are asymptomatic or mild, some cases can be deadly and disastrous, and physicians should be aware that if myocarditis is suspected based on clinical symptoms, troponin, electrocardiogram, and echocardiogram, treatment should be initiated accordingly.
Collapse
Affiliation(s)
- Ali Moradi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Athri Kodali
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Chiugo Okoye
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Dhadon Hannah Klein
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Iman Mohamoud
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Olawale O Olanisa
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Panah Parab
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Priti Chaudhary
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sonia Mukhtar
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| |
Collapse
|
13
|
Delombaerde D, De Sutter J, Croes L, Vervloet D, Moerman V, Van de Veire N, Willems AM, Wouters K, Peeters M, Prenen H, Vulsteke C. Extensive CArdioVAscular Characterization and Follow-Up of Patients Receiving Immune Checkpoint Inhibitors: A Prospective Multicenter Study. Pharmaceuticals (Basel) 2023; 16:ph16040625. [PMID: 37111382 PMCID: PMC10142365 DOI: 10.3390/ph16040625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The increasing use of immune checkpoint inhibitors (ICIs) in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in the incidence of cardiovascular (CV) immune-related adverse events (irAEs). The current follow-up guidelines are based on anecdotal evidence and expert opinions, due to a lack of solid data and prospective studies. As many questions remain unanswered, cardiac monitoring, in patients receiving ICIs, is not always implemented by oncologists. Hence, an urgent need to investigate the possible short- and long-term CV effects of ICIs, as ICI approval is continuing to expand to the (neo)adjuvant setting. METHODS We have initiated a prospective, multicenter study, i.e., the CAVACI trial, in which a minimum of 276 patients with a solid tumor, eligible for ICI treatment, will be enrolled. The study consists of routine investigations of blood parameters (troponin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, in particular) and a thorough CV follow-up (electrocardiograms, transthoracic echocardiograms, and coronary calcium scoring) at fixed time points for a total period of two years. The primary endpoint is the cumulative incidence of troponin elevation in the first three months of ICI treatment, compared to baseline levels. Furthermore, secondary endpoints include incidence above the upper limit of normal of both troponin and NT-proBNP levels, evolution in troponin and NT-proBNP levels, the incidence of CV abnormalities/major adverse cardiac events, evaluation of associations between patient characteristics/biochemical parameters and CV events, transthoracic echocardiography parameters, electrocardiography parameters, and progression of coronary atherosclerosis. Recruitment of patients started in January 2022. Enrolment is ongoing in AZ Maria Middelares, Antwerp University Hospital, AZ Sint-Vincentius Deinze, and AZ Sint-Elisabeth Zottegem. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05699915, registered 26 January 2023.
Collapse
Affiliation(s)
- Danielle Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | - Johan De Sutter
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | - Lieselot Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | | | | | - Nico Van de Veire
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Department of Cardiology, Free University Brussels, 1000 Brussels, Belgium
| | | | - Kristien Wouters
- Antwerp University Hospital, Clinical Trial Center (CTC), CRC Antwerp, 2650 Edegem, Belgium
| | - Marc Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Hans Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Christof Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| |
Collapse
|
14
|
Grigorescu A, Teodorescu M. Toxicitatea cardiacă a inhibitorilor punctelor de control (IPC) utilizaţi în imunoterapia cancerului. ONCOLOG-HEMATOLOG.RO 2023. [DOI: 10.26416/onhe.62.1.2023.7746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
|
15
|
Lopez-Mattei J, Yang EH, Baldassarre LA, Agha A, Blankstein R, Choi AD, Chen MY, Meyersohn N, Daly R, Slim A, Rochitte C, Blaha M, Whelton S, Dzaye O, Dent S, Milgrom S, Ky B, Iliescu C, Mamas MA, Ferencik M. Cardiac computed tomographic imaging in cardio-oncology: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). Endorsed by the International Cardio-Oncology Society (ICOS). J Cardiovasc Comput Tomogr 2023; 17:66-83. [PMID: 36216699 DOI: 10.1016/j.jcct.2022.09.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/01/2022] [Accepted: 09/12/2022] [Indexed: 11/21/2022]
Abstract
Cardio-Oncology is a rapidly growing sub-specialty of medicine, however, there is very limited guidance on the use of cardiac CT (CCT) in the care of Cardio-Oncology patients. In order to fill in the existing gaps, this Expert Consensus statement comprised of a multidisciplinary collaboration of experts in Cardiology, Radiology, Cardiovascular Multimodality Imaging, Cardio-Oncology, Oncology and Radiation Oncology aims to summarize current evidence for CCT applications in Cardio-Oncology and provide practice recommendations for clinicians.
Collapse
Affiliation(s)
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Ali Agha
- Department of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Ron Blankstein
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew D Choi
- Division of Cardiology and Department of Radiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Marcus Y Chen
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nandini Meyersohn
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, USA
| | - Ryan Daly
- Franciscan Health Indianapolis, Indianapolis, IN, USA
| | | | - Carlos Rochitte
- InCor Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Michael Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Seamus Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, NC, USA
| | - Sarah Milgrom
- Department of Radiation Oncology, University of Colorado, Boulder, CO, USA
| | - Bonnie Ky
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Cezar Iliescu
- Heart and Vascular Institute, Lee Health, Fort Myers, FL, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
16
|
Park BC, Narayanan S, Gavraldis A, Ye F, Fan R, Sullivan RJ, Boland G, Reynolds KL, Balko JM, Carlino MS, Long GV, Zubiri L, Menzies AM, Johnson DB. Rare immune-related adverse events in patients with melanoma: incidence, spectrum, and clinical presentations. Oncoimmunology 2023; 12:2188719. [PMID: 36926262 PMCID: PMC10012911 DOI: 10.1080/2162402x.2023.2188719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2023] Open
Abstract
Immune-related adverse events (irAEs) are side effects of immune checkpoint inhibitor therapy (ICI). While common irAEs have been well characterized, there are more limited data on rare immune related adverse events (RirAEs) due to low incidence. Lack of characterization of these entities has led to difficulties in accurate diagnosis and management. Here, we conducted a multi-institution analysis of all patients with stage III/IV melanoma who developed RirAEs after being treated with ICIs (anti-PD-1/L1, anti-CTLA-4, and combination PD-1/CTLA-4 blockade) at three institutions (Vanderbilt University Medical Center, Massachusetts General Hospital, and Melanoma Institute of Australia). RirAEs were defined as those occurring in approximately <1% of patients treated with anti-PD-1 or <2% with combination. Of 2834 patients who received ICIs, 82 developed RirAEs and were more common with combination PD-1/CTLA-4 blockade (4.6%) vs. anti-PD-1/L1 agents (2.8%). Overall median time from ICI start to RirAE was 86 days (interquartile range 42-235 days) with significantly earlier onset in combination therapy (p < 0.001). The spectrum of RirAEs spanned across several organ systems. Most RirAEs were grade 2 (57 [41.3%]) and grade 3 (40 [29.0%]) with relatively few grade 4 (11 [8.0%]) or 5 (5 [3.6%]) events. Steroid re-escalation (21.4%) or additional immunosuppression (13.8%) were commonly required. RirAE recurrence occurred in 22.6% with ICI rechallenge; 37.1% had new irAEs with rechallenge. In conclusion, RirAEs associated with ICIs in melanoma patients occurred, in aggregate, in 2-5% of patients treated with anti-PD-1-based therapy. Steroid re-escalation and alternative immunosuppression use were frequently required but fatal irAEs were fairly uncommon.
Collapse
Affiliation(s)
- Benjamin C Park
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Sathya Narayanan
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - Alexander Gavraldis
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Run Fan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan J Sullivan
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Genevieve Boland
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Kerry L Reynolds
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Justin M Balko
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matteo S Carlino
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, NSW, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Leyre Zubiri
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
17
|
Ye Y, Li Y, Zhang S, Han G. Teriprizumab-induced myocarditis in a patient with cholangiocarcinoma: a case report. J Int Med Res 2022; 50:3000605221133259. [PMID: 36300305 PMCID: PMC9620143 DOI: 10.1177/03000605221133259] [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: 11/07/2022] Open
Abstract
With the extensive use of immune checkpoint inhibitors (ICI) in advanced-stage
cancers, immune-related adverse events (irAEs) have been noted in various
systems. While most irAEs are reversible and manageable, cardiac toxicities are
rare but life-threatening, with high mortality rates. We present a case of a
71-year-old man with cholangiocarcinoma who developed myocarditis related to
ICIs 29 days after the first infusion of teriprizumab combined with
albumin-bound paclitaxel and gemcitabine. He was initially asymptomatic after
admission but with substantial elevations of troponin I and myocardial enzymes.
Sixteen hours after admission, he developed palpitations, dizziness, and
syncope. Electrocardiography confirmed third-degree atrioventricular block and
frequent ventricular premature contractions for which he received high-dose
corticosteroids and a permanent pacemaker. The patient survived and permanently
discontinued immunotherapy. Early identification and intervention are the keys
to improving the prognosis of immune myocarditis.
Collapse
Affiliation(s)
| | | | | | - Gaohua Han
- Gaohua Han, Department of Oncology, Taizhou
People's Hospital, 399 Hailing South Road, Hailing District, Taizhou, Jiangsu
225300, P. R. China.
| |
Collapse
|
18
|
Ganesh S, Zhong P, Zhou X. Cardiotoxicity induced by immune checkpoint inhibitor: The complete insight into mechanisms, monitoring, diagnosis, and treatment. Front Cardiovasc Med 2022; 9:997660. [PMID: 36204564 PMCID: PMC9530557 DOI: 10.3389/fcvm.2022.997660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have been taking cancer research by storm as they provide valuable therapeutic benefits to cancer patients in terms of immunotherapy. Melanoma and non-small cell lung cancer (NSCLC) are among the most prevalent cancer varieties that were utilized in ICI trials with many other cancer types being involved too. Despite impressive clinical benefits of overall response rate (ORR), progression-free survival (PFS), etc., ICIs are also accompanied by various immune-related adverse events (irAEs). Amongst the irAEs, cardiotoxicity bags a crucial role. It is of paramount importance that ICI-induced cardiotoxicity should be studied in detail due to its high mortality rate although the prevalence rate is low. Patients with ICI cardiotoxicity can have a greatly enhanced life quality despite adverse reactions from ICI therapy if diagnosed early and treated in time. As such, this review serves to provide a complete insight into the predisposing factors, mechanism, diagnostic methods and treatment plans revolving around ICI-induced cardiotoxicity.
Collapse
|
19
|
Quagliariello V, Passariello M, Di Mauro A, Cipullo C, Paccone A, Barbieri A, Palma G, Luciano A, Buccolo S, Bisceglia I, Canale ML, Gallucci G, Inno A, De Lorenzo C, Maurea N. Immune checkpoint inhibitor therapy increases systemic SDF-1, cardiac DAMPs Fibronectin-EDA, S100/Calgranulin, galectine-3, and NLRP3-MyD88-chemokine pathways. Front Cardiovasc Med 2022; 9:930797. [PMID: 36158826 PMCID: PMC9505026 DOI: 10.3389/fcvm.2022.930797] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/03/2022] [Indexed: 11/15/2022] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) have significantly changed the oncology clinic in recent years, improving survival expectations in cancer patients. ICI therapy have a broad spectrum of side effects from endocrinopathies to cardiovascular diseases. In this study, pro-inflammatory and pro-fibrotic effects of short-term ICIs therapy in preclinical models were analyzed. Methods Firstly, in a human in vitro model, human cardiomyocytes co-cultured with hPBMC were exposed to ICIs (with CTLA-4 or PD-1 blocking agents, at 200 nM) for 72 h. After treatment, production of DAMPs and 12 cytokines were analyzed in the supernatant through colorimetric and enzymatic assays. C57/Bl6 mice were treated with CTLA-4 or PD-1 blocking agents (15 mg/kg) for 10 days. Before (T0), after three days (T3) and after treatments (T10), ejection fraction, fractional shortening, radial and longitudinal strain were calculated by using bidimensional echocardiography (Vevo 2100, Fujfilm). Fibrosis, necrosis, hypertrophy and vascular NF-kB expression were analyzed through Immunohistochemistry. Myocardial expression of DAMPs (S100- Calgranulin, Fibronectin and Galectine-3), MyD88, NLRP3 and twelve cytokines have been analyzed. Systemic levels of SDF-1, IL-1β, and IL-6 were analyzed before, during and after ICIs therapy. Results Radial and longitudinal strain were decreased after 10 days of ICIs therapy. Histological analysis of NF-kB expression shows that short-term anti-CTLA-4 or anti-PD-1 treatment increased vascular and myocardial inflammation. No myocardial hypertrophy was seen with the exception of the pembrolizumab group. Myocardial fibrosis and expression of galectin-3, pro-collagen 1-α and MMP-9 were increased after treatment with all ICIs. Both anti-CTLA-4 or anti-PD-1 treatments increased the expression of DAMPs, NLRP3 inflammasome and MyD88 and induced both in vitro and in vivo the secretion of IL-1β, TNF-α and IL-6. Systemic levels of SDF-1, IL-1β and IL-6 were increased during and after treatment with ICIs. Conclusions Short therapy with PD-1 and CTLA-4 blocking agents increases vascular expression of NF-kB, systemic SDF-1, IL-1β, IL-6 levels and myocardial NLRP3, MyD88 and DAMPs expression in preclinical models. A pro-inflammatory cytokine storm was induced in myocardial tissues and in cultured cardiac cells after ICIs therapy. The overall picture of the study suggests new putative biomarkers of ICIs-mediated systemic and myocardial damages potentially useful in clinical cardioncology.
Collapse
Affiliation(s)
- Vincenzo Quagliariello
- Division of Cardiology, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy,*Correspondence: Vincenzo Quagliariello
| | - Margherita Passariello
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Naples, Italy,Ceinge-Biotecnologie Avanzate s.c.a.r.l., Naples, Italy
| | - Annabella Di Mauro
- Pathology Unit, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Ciro Cipullo
- Pathology Unit, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Andrea Paccone
- Division of Cardiology, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Antonio Barbieri
- Animal Facility, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Giuseppe Palma
- Animal Facility, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Antonio Luciano
- Animal Facility, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Simona Buccolo
- Division of Cardiology, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Irma Bisceglia
- Servizi Cardiologici Integrati, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Maria Laura Canale
- U.O.C. Cardiologia, Ospedale Versilia, Lido di Camaiore (LU), Camaiore, Italy
| | - Giuseppina Gallucci
- Cardiologia, Centro di Riferimento Oncologico della Basilicata (CROB) - Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rionero in Vulture, Italy
| | - Alessandro Inno
- Medical Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Sacro Cuore Don Calabria, Negrar, Italy
| | - Claudia De Lorenzo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Naples, Italy,Ceinge-Biotecnologie Avanzate s.c.a.r.l., Naples, Italy
| | - Nicola Maurea
- Division of Cardiology, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy,Nicola Maurea
| |
Collapse
|
20
|
Laenens D, Yu Y, Santens B, Jacobs J, Beuselinck B, Bechter O, Wauters E, Staessen J, Janssens S, Van Aelst L. Incidence of Cardiovascular Events in Patients Treated With Immune Checkpoint Inhibitors. J Clin Oncol 2022; 40:3430-3438. [PMID: 35772044 DOI: 10.1200/jco.21.01808] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE In rare cases, immune checkpoint inhibitors (ICIs) cause immune-mediated myocarditis. However, true incidence of other major adverse cardiovascular events (MACEs) after ICI treatment remains unknown, mainly because late occurring side effects are rarely reported in prospective clinical trials. The aims of this study were (1) to identify incidence and risk factors of MACE in a real-life ICI-treated cancer cohort and (2) to compare incidence rates with patients with cancer who are not treated with ICIs and population controls. METHODS In total, 672 patients treated with ICIs were included. The primary end point was MACE, a composite of acute coronary syndrome, heart failure (HF), stroke, and transient ischemic attack. Secondary outcomes were acute coronary syndrome and HF separately. Incidence rates were compared between groups after matching according to age, sex, cardiovascular history, and cancer type. RESULTS The incidence of MACE was 10.3% during a median follow-up of 13 (interquartile range 6-22) months. In multivariable analysis, a history of HF (hazard ratio 2.27; 95% CI, 1.03 to 5.04; P = .043) and valvular heart disease (hazard ratio 3.01; 95% CI, 1.05 to 8.66; P = .041) remained significantly associated with MACE. Cumulative incidence rates were significantly higher in the ICI group compared with the cancer cohort not exposed to ICI and the population controls, mainly driven by a higher risk of HF events. CONCLUSION Cardiovascular events during and after ICI treatment are more common than currently appreciated. Patients at risk are those with a history of cardiovascular disease. Compared with matched cancer and population controls, MACE incidence rates are significantly higher, suggesting a potential harmful effect of ICI treatment besides the underlying risk.
Collapse
Affiliation(s)
- Dorien Laenens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Yuling Yu
- Research Unit Environment and Health, KU Leuven Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
| | - Béatrice Santens
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Johanna Jacobs
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Benoit Beuselinck
- Department of Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Oliver Bechter
- Department of Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Els Wauters
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Staessen
- Non-Profit Research Institute, Alliance for the Promotion of Preventive Medicine, Mechelen, Belgium.,Biomedical Sciences Group, Faculty of Medicine, University of Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| |
Collapse
|
21
|
Tyebally S, Ghose A, Chen DH, Abiodun AT, Ghosh AK. Chest Pain in the Cancer Patient. Eur Cardiol 2022; 17:e15. [PMID: 35702571 PMCID: PMC9185574 DOI: 10.15420/ecr.2021.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022] Open
Abstract
Chest pain is one of the most common presenting symptoms in patients seeking care from a physician. Risk assessment tools and scores have facilitated prompt diagnosis and optimal management in these patients; however, it is unclear as to whether a standardised approach can adequately triage chest pain in cancer patients and survivors. This is of concern because cancer patients are often at an increased risk of cardiovascular mortality and morbidity given the shared risk factors between cancer and cardiovascular disease, compounded by the fact that certain anti-cancer therapies are associated with an increased risk of cardiovascular events that can persist for weeks and even years after treatment. This article describes the underlying mechanisms of the most common causes of chest pain in cancer patients with an emphasis on how their management may differ to that of non-cancer patients with chest pain. It will also highlight the role of the cardio-oncology team, who can aid in identifying cancer therapy-related cardiovascular side-effects and provide optimal multidisciplinary care for these patients.
Collapse
Affiliation(s)
- Sara Tyebally
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
| | - Aruni Ghose
- Oncology Department, St Bartholomew’s Hospital, London, UK
| | - Daniel H Chen
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew’s Hospital, London, UK; Hatter Cardiovascular Institute, UCL Institute of Cardiovascular Science, University College London Hospital, London, UK
| | - Aderonke T Abiodun
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
| | - Arjun K Ghosh
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew’s Hospital, London, UK; Hatter Cardiovascular Institute, UCL Institute of Cardiovascular Science, University College London Hospital, London, UK
| |
Collapse
|
22
|
Ronen D, Bsoul A, Lotem M, Abedat S, Yarkoni M, Amir O, Asleh R. Exploring the Mechanisms Underlying the Cardiotoxic Effects of Immune Checkpoint Inhibitor Therapies. Vaccines (Basel) 2022; 10:vaccines10040540. [PMID: 35455289 PMCID: PMC9031363 DOI: 10.3390/vaccines10040540] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/15/2022] [Accepted: 03/24/2022] [Indexed: 02/01/2023] Open
Abstract
Adaptive immune response modulation has taken a central position in cancer therapy in recent decades. Treatment with immune checkpoint inhibitors (ICIs) is now indicated in many cancer types with exceptional results. The two major inhibitory pathways involved are cytotoxic T-lymphocyte-associated protein 4 (CTLA4) and programmed cell death protein 1 (PD-1). Unfortunately, immune activation is not tumor-specific, and as a result, most patients will experience some form of adverse reaction. Most immune-related adverse events (IRAEs) involve the skin and gastrointestinal (GI) tract; however, any organ can be involved. Cardiotoxicity ranges from arrhythmias to life-threatening myocarditis with very high mortality rates. To date, most treatments of ICI cardiotoxicity include immune suppression, which is also not cardiac-specific and may result in hampering of tumor clearance. Understanding the mechanisms behind immune activation in the heart is crucial for the development of specific treatments. Histological data and other models have shown mainly CD4 and CD8 infiltration during ICI-induced cardiotoxicity. Inhibition of CTLA4 seems to result in the proliferation of more diverse T0cell populations, some of which with autoantigen recognition. Inhibition of PD-1 interaction with PD ligand 1/2 (PD-L1/PD-L2) results in release from inhibition of exhausted self-recognizing T cells. However, CTLA4, PD-1, and their ligands are expressed on a wide range of cells, indicating a much more intricate mechanism. This is further complicated by the identification of multiple co-stimulatory and co-inhibitory signals, as well as the association of myocarditis with antibody-driven myasthenia gravis and myositis IRAEs. In this review, we focus on the recent advances in unraveling the complexity of the mechanisms driving ICI cardiotoxicity and discuss novel therapeutic strategies for directly targeting specific underlying mechanisms to reduce IRAEs and improve outcomes.
Collapse
Affiliation(s)
- Daniel Ronen
- Department of Internal Medicine D, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - Aseel Bsoul
- Cardiovascular Research Center, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.B.); (S.A.); (O.A.)
| | - Michal Lotem
- Department of Oncology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - Suzan Abedat
- Cardiovascular Research Center, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.B.); (S.A.); (O.A.)
| | - Merav Yarkoni
- Department of Cardiology, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - Offer Amir
- Cardiovascular Research Center, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.B.); (S.A.); (O.A.)
- Department of Cardiology, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - Rabea Asleh
- Cardiovascular Research Center, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.B.); (S.A.); (O.A.)
- Department of Cardiology, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
- Correspondence: ; Tel.: +972-2-6776564; Fax: +972-2-6411028
| |
Collapse
|
23
|
Rini BI, Moslehi JJ, Bonaca M, Schmidinger M, Albiges L, Choueiri TK, Motzer RJ, Atkins MB, Haanen J, Mariani M, Wang J, Hariharan S, Larkin J. Prospective Cardiovascular Surveillance of Immune Checkpoint Inhibitor-Based Combination Therapy in Patients With Advanced Renal Cell Cancer: Data From the Phase III JAVELIN Renal 101 Trial. J Clin Oncol 2022; 40:1929-1938. [PMID: 35239416 PMCID: PMC9177241 DOI: 10.1200/jco.21.01806] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Both immune checkpoint inhibitors (ICIs) and vascular endothelial growth factor receptor (VEGFR) inhibitors are approved for advanced renal cell carcinoma treatment and can cause cardiovascular events (CVs); thus, combination therapy could lead to major adverse CV events (MACE). Cardiac serum biomarker assessment and imaging, including left ventricular ejection fraction (LVEF) monitoring, can be used to evaluate MACE. METHODS To our knowledge, the JAVELIN Renal 101 trial, assessing avelumab plus axitinib versus sunitinib in patients with advanced renal cell carcinoma, is the first randomized study of ICI plus VEGFR inhibitor treatment to include prospective serial cardiac monitoring of LVEF and serum cardiac biomarkers. RESULTS MACE (defined as grade ≥ 3 CV AEs) occurred in 31 patients (7.1%) in the combination arm and 17 patients (3.9%) in the sunitinib arm. Patients in the combination arm who had high baseline troponin T values were at higher risk of MACE versus patients with low values (MACE in 6/35 v 7/135, respectively; relative risk, 3.31; 95% CI, 1.19 to 9.22). This association was not observed in patients treated with sunitinib. Other CV baseline risk factors and serum cardiac biomarkers were not significantly predictive for MACE, although a trend toward an association with dyslipidemia was seen in the combination arm. No clinical value of on-treatment routine monitoring of LVEF in relation to MACE was observed. Although LVEF decline was significantly more frequent in the combination arm, most patients recovered, and decline was not associated with other significant cardiac events or symptoms. CONCLUSION Patients with high baseline troponin T levels receiving ICI and VEGFR combinations may need to be monitored more closely for MACE. Routine monitoring of LVEF in asymptomatic patients is not recommended.
Collapse
Affiliation(s)
- Brian I Rini
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Javid J Moslehi
- Section of Cardio-Oncology & Immunology, Division of Cardiology, Cardiovascular Research Institute, University of California San Francisco School of Medicine, San Francisco, CA.,Vanderbilt University Medical Center, Nashville, TN
| | - Marc Bonaca
- Colorado Prevention Center Clinical Research, Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Manuela Schmidinger
- Department of Urology and Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel, Vienna, Austria
| | - Laurence Albiges
- Medical Oncology Department, Institut Gustave Roussy, Villejuif, France
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | | | | | - John Haanen
- Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | | | | | - James Larkin
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
24
|
Vetrei C, Passariello M, Froechlich G, Rapuano Lembo R, Sasso E, Zambrano N, De Lorenzo C. Novel Combinations of Human Immunomodulatory mAbs Lacking Cardiotoxic Effects for Therapy of TNBC. Cancers (Basel) 2021; 14:cancers14010121. [PMID: 35008285 PMCID: PMC8750931 DOI: 10.3390/cancers14010121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Immunotherapy has revolutionized the management of cancer by improving outcomes of triple-negative breast cancer (TNBC). Recently, programmed death-ligand 1 (PD-L1), was identified as a target for TNBC and several preclinical and clinical trials are currently focusing on combinatorial treatments of immunomodulatory mAbs with chemotherapy, radiotherapy, or other mAbs. Here, we tested in in vitro models novel combinations of immunomodulatory mAbs on TNBC cell lines and on cardiomyocytes, in comparison with the mAbs approved by FDA for cancer therapy, in order to identify at early stages the more potent anti-cancer combinations endowed with low or no cardiotoxic side effects. Abstract Triple-negative breast cancer (TNBC) is a highly aggressive subtype of breast cancer characterized by a higher mortality rate among breast cancer subtypes. Poly(ADP-ribose) polymerase (PARP) inhibitors are used in clinics to treat a subgroup of TNBC patients, but other targeted therapies are urgently needed. Programmed death-ligand 1 (PD-L1), involved in tumor immune escape, was recently identified as a target for TNBC; accordingly, the anti-PD-L1 monoclonal antibody (mAb), atezolizumab, has been approved by FDA in combination with Paclitaxel for the therapy of metastatic TNBC. Here, we tested novel combinations of fully human immunomodulatory mAbs, including anti-PD-L1 mAbs generated in our laboratory and atezolizumab, on TNBC and other tumor cell lines. We evaluated their anti-tumor efficacy when used as single agents or in combinatorial treatments with anti-CTLA-4 mAbs in in vitro co-cultures of hPBMCs with tumor cells, by measuring tumor cell lysis and IL-2 and IFNγ cytokines secretion by lymphocytes. In parallel, by using co-cultures of hPBMCs and cardiomyocytes, we analyzed the potential cardiotoxic adverse side effects of the same antibody treatments by measuring the cardiac cell lysis and the secretion of pro-inflammatory cytokines. We identified novel combinations of immunomodulatory mAbs endowed with more potent anti-cancer activity on TNBC and lower cardiotoxic side effects than the combination of atezolizumab and ipilimumab.
Collapse
Affiliation(s)
- Cinzia Vetrei
- Ceinge—Biotecnologie Avanzate s.c.a.r.l., Via Gaetano Salvatore 486, 80145 Naples, Italy; (C.V.); (M.P.); (G.F.); (R.R.L.); (E.S.); (N.Z.)
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Via Pansini 5, 80131 Napoli, Italy
| | - Margherita Passariello
- Ceinge—Biotecnologie Avanzate s.c.a.r.l., Via Gaetano Salvatore 486, 80145 Naples, Italy; (C.V.); (M.P.); (G.F.); (R.R.L.); (E.S.); (N.Z.)
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Via Pansini 5, 80131 Napoli, Italy
| | - Guendalina Froechlich
- Ceinge—Biotecnologie Avanzate s.c.a.r.l., Via Gaetano Salvatore 486, 80145 Naples, Italy; (C.V.); (M.P.); (G.F.); (R.R.L.); (E.S.); (N.Z.)
- European School of Molecular Medicine, University of Milan, 20122 Milan, Italy
| | - Rosa Rapuano Lembo
- Ceinge—Biotecnologie Avanzate s.c.a.r.l., Via Gaetano Salvatore 486, 80145 Naples, Italy; (C.V.); (M.P.); (G.F.); (R.R.L.); (E.S.); (N.Z.)
- European School of Molecular Medicine, University of Milan, 20122 Milan, Italy
| | - Emanuele Sasso
- Ceinge—Biotecnologie Avanzate s.c.a.r.l., Via Gaetano Salvatore 486, 80145 Naples, Italy; (C.V.); (M.P.); (G.F.); (R.R.L.); (E.S.); (N.Z.)
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Via Pansini 5, 80131 Napoli, Italy
| | - Nicola Zambrano
- Ceinge—Biotecnologie Avanzate s.c.a.r.l., Via Gaetano Salvatore 486, 80145 Naples, Italy; (C.V.); (M.P.); (G.F.); (R.R.L.); (E.S.); (N.Z.)
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Via Pansini 5, 80131 Napoli, Italy
| | - Claudia De Lorenzo
- Ceinge—Biotecnologie Avanzate s.c.a.r.l., Via Gaetano Salvatore 486, 80145 Naples, Italy; (C.V.); (M.P.); (G.F.); (R.R.L.); (E.S.); (N.Z.)
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Via Pansini 5, 80131 Napoli, Italy
- Correspondence: ; Tel.: +39-081-373-7868
| |
Collapse
|
25
|
Sun JY, Qu Q, Lou YX, Hua Y, Sun GZ, Sun W, Kong XQ. Cardiotoxicity in cancer immune-checkpoint therapy: Mechanisms, clinical evidence, and management strategies. Int J Cardiol 2021; 344:170-178. [PMID: 34563597 DOI: 10.1016/j.ijcard.2021.09.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/30/2021] [Accepted: 09/20/2021] [Indexed: 12/17/2022]
Abstract
Immune-checkpoint inhibitors (ICIs), a unique antibody-based therapeutic strategy, have revolutionized the treatment landscape of solid and hematological cancers. Despite the proven benefits of ICIs, the cardiotoxicity from unspecific immune activation (uncommon but potentially fatal) is a continuing concern. Accumulating preclinical research has demonstrated that ICIs initiate inflammation in the myocardium, while clinically significant cardiotoxicity were reported in few patients receiving ICI therapy, probably due to the low incidence and unspecific symptoms. The subtle signs and symptoms (e.g., chest pain, dizziness, and dyspnea) were likely attributed to cancer and/or non-cardiac events by previous studies, thus limiting the understanding of the incidence, outcomes, risk factors, and management of ICI-related cardiotoxicity. The heterogeneous clinical presentation and complex diagnostic procedure further make it challenging to accurately identify ICI-related cardiac events in clinical trials. Therefore, ICI-related cardiotoxicity, whose incidence is probably underestimated, has not been well recognized. In this article, we provide an overview of potential mechanisms underlying ICI-related cardiotoxicity and review accumulating clinical evidence of ICI-related cardiotoxicity, with a focus on myocarditis. Moreover, we discuss possible strategies to manage ICI-related cardiotoxicity and highlight the importance of developing cardio-oncology.
Collapse
Affiliation(s)
- Jin-Yu Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Qiang Qu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Yu-Xuan Lou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Yang Hua
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Guo-Zhen Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Wei Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China..
| | - Xiang-Qing Kong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China..
| |
Collapse
|
26
|
Johannsen M, Stoll C, Raida M, van Oorschot B, Flörcken A. Supportive therapy and complementary medicine in renal cell carcinoma. World J Urol 2021; 40:2359-2371. [PMID: 34821959 DOI: 10.1007/s00345-021-03885-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE As part of the German interdisciplinary S3-guideline "Diagnosis, Treatment and Followup of Renal Cell Carcinoma", this article aimes to provide guidance regarding the use of supportive therapy and complementary medicine in patients with advanced or metastatic renal cell carcinoma. METHODS The German interdisciplinary S3-guidelines are national clinical practice guidelines that implement the highest methodological quality of evidence-based medicine. Recommendations and evidence-based statements are provided according to available evidence. RESULTS Supportive and palliative care are important areas of tumor treatment and require knowledge on the management of a variety of issues. This article outlines the management of tumor-related symptoms such as pain, undesired treatment-related effects, palliative care and end-of-life care in patients with renal cell carcinoma. CONCLUSION Patients with advanced or metastatic renal cell carcinoma should have access to supportive and palliative care according to their individual needs. There is very limited evidence regarding the impact of complementary medicine for the treatment of patients with renal cell carcinoma.
Collapse
Affiliation(s)
- M Johannsen
- Urology Practice Johannsen & Laux, Berlin and d-uo (Deutsche Uro-Onkologen), Berlin, Germany
| | - C Stoll
- Department of Oncology, Clinic Herzoghoehe, Bayreuth, Germany
| | - M Raida
- VAMED Rehabilitation Clinic Bergisch-Land, Wuppertal, Germany
| | - B van Oorschot
- Interdisciplinary Center for Palliative Medicine, Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
| | - A Flörcken
- Department of Hematology, Oncology, and Tumor Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| |
Collapse
|
27
|
Schneider BJ, Naidoo J, Santomasso BD, Lacchetti C, Adkins S, Anadkat M, Atkins MB, Brassil KJ, Caterino JM, Chau I, Davies MJ, Ernstoff MS, Fecher L, Ghosh M, Jaiyesimi I, Mammen JS, Naing A, Nastoupil LJ, Phillips T, Porter LD, Reichner CA, Seigel C, Song JM, Spira A, Suarez-Almazor M, Swami U, Thompson JA, Vikas P, Wang Y, Weber JS, Funchain P, Bollin K. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update. J Clin Oncol 2021; 39:4073-4126. [PMID: 34724392 DOI: 10.1200/jco.21.01440] [Citation(s) in RCA: 624] [Impact Index Per Article: 208.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with immune checkpoint inhibitor (ICPi) therapy. METHODS A multidisciplinary panel of medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to update the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 through 2021. RESULTS A total of 175 studies met the eligibility criteria of the systematic review and were pertinent to the development of the recommendations. Because of the paucity of high-quality evidence, recommendations are based on expert consensus. RECOMMENDATIONS Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to the organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, except for some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert ≤ grade 1. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids. Corticosteroids should be tapered over the course of at least 4-6 weeks. Some refractory cases may require other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, except for endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines.
Collapse
Affiliation(s)
| | - Jarushka Naidoo
- Beaumont Hospital, Dublin, Ireland.,Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | | | | | | | | | | | - Ian Chau
- Royal Marsden Hospital and Institute of Cancer Research, London & Surrey, Sutton, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Umang Swami
- Huntsman Cancer Institute-University of Utah, Salt Lake City, UT
| | - John A Thompson
- Seattle Cancer Care Alliance, University of Washington/Fred Hutchinson, Seattle, WA
| | | | | | | | | | | |
Collapse
|
28
|
Role of Cardiac Biomarkers in Cancer Patients. Cancers (Basel) 2021; 13:cancers13215426. [PMID: 34771589 PMCID: PMC8582425 DOI: 10.3390/cancers13215426] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 02/02/2023] Open
Abstract
Simple Summary Cardiac biomarkers have proved increasingly useful in the various branches of cardiology, not sparing the field of cardio-oncology. With specific reference to the latter subject, they have been investigated as predictors and/or diagnostic and monitoring tools, as well as prognostic factors, with the purpose of allowing the early prevention of many cardiovascular complications related to the direct action of some cancer types or related to the toxicity of its treatments. However, despite this great potential and excellent cost-effectiveness, their usefulness in some areas still seems to be limited due to lack of sufficient specificity or sensitivity. In fact, in clinical practice, while their use is nowadays standard in some circumstances, evidence does not yet support their routine use in other cases. Abstract In patients with cancer—and especially some specific subtypes—the heart can be pathologically affected due to the direct action of the tumor or its secretion products or due to the toxicity of some oncological treatments. Cardiac biomarkers have been investigated as inexpensive and easily accessible tools for prediction, early diagnosis, monitoring, or prognosis of various forms of cancer-related cardiac diseases. However, their clinical usefulness was not always clearly demonstrated in every area of cardioncology. For the identification of anthracycline related cardiotoxicity in the very early stages troponins proved to be more efficient detectors than imaging methods. Nevertheless, the lack of a standardized dosage methodology and of cardiotoxicity specific thresholds, do not yet allow to outline the precise way to employ them in clinical routine and to incorporate them into appropriate diagnostic or managing algorithms. Cardiac biomarkers proved also effective in patients with primary cardiac amyloidosis, in which both troponins and natriuretic peptides were able to predict adverse outcome, and carcinoid heart disease, where a precise diagnostic cut-off for N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was identified to screen patients with valvular involvement. Likewise, NT-proBNP proved to be an excellent predictor of postoperative atrial fibrillation (POAF). On the contrary, evidence is still not sufficient to promote the routine use of cardiac biomarkers to early diagnose myocarditis due to immune check points inhibitors (ICIs), radiotherapy induced cardiotoxicity and cardiac complications related to androgenetic deprivation. In this review we present all the evidence gathered so far regarding the usefulness and limitations of these relatively inexpensive diagnostic tools in the field of cardio-oncology.
Collapse
|
29
|
Thakker RA, Lee MA, Albaeni A, Elbadawi A, Suthar KH, Perez C, Sonstein LK, Farr NM, Venkatesan R, Khalife W, Berbarie RF, Chatila KF. Clinical Characteristics and Outcomes in Immune Checkpoint Inhibitor Therapy-Associated Myocarditis. Cardiol Res 2021; 12:270-278. [PMID: 34691324 PMCID: PMC8510657 DOI: 10.14740/cr1319] [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: 08/31/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) therapy has played an important role in the treatment of several groups of cancers. Although a life prolonging treatment, many side effects have been shown with ICI therapy. This study looked at individual level clinical characteristics and outcomes with ICI therapy in patients who developed ICI-related myocarditis. A comprehensive review of the National Library of Medicine PubMed database was performed. Inclusion criteria were all studies that were composed of case reports and case series of individual patients undergoing ICI therapy that developed myocarditis. To appreciate individual patient level data, observational studies, clinical trials, systematic reviews, and meta-analyses were excluded. Our search yielded 333 results with 71 cases reviewed of ICI therapy-related myocarditis. The findings included an average age of 68 years, higher incidence in men, and pretreatment cardiac history of hypertension. Melanoma was the most prevalent malignancy with nivolumab being the most used ICI therapy. Heart failure was the most prevalent adverse event that was co-prevalent with myocarditis. Corticosteroid therapy alone was the most utilized therapy to treat ICI-related myocarditis. Mortality was seen in nearly half of the patient population. Our study reviewed the preexisting literature of prior reported myocarditis secondary to ICI therapy. Periodic surveillance should be performed by the cardio-oncologist and internist. Due to the expanding role of ICI therapy in treating a variety of cancer patients, appreciation of its impact on the development of myocarditis is needed.
Collapse
Affiliation(s)
- Ravi A Thakker
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Marissa A Lee
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Aiham Albaeni
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Ayman Elbadawi
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Krishna H Suthar
- Department of Hematology and Medical Oncology, Baylor Scott and White Medical Center, Temple, TX, USA
| | - Christopher Perez
- Cardiovascular Institute, Baylor Scott and White Medical Center, Temple, TX, USA
| | - Lindsay K Sonstein
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Norman M Farr
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Rohit Venkatesan
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Galveston, TX, USA
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Rafic F Berbarie
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Khaled F Chatila
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| |
Collapse
|
30
|
Shalata W, Abu-salman A, Steckbeck R, Mathew Jacob B, Massalha I, Yakobson A. Cardiac Toxicity Associated with Immune Checkpoint Inhibitors: A Systematic Review. Cancers (Basel) 2021; 13:5218. [PMID: 34680365 PMCID: PMC8534225 DOI: 10.3390/cancers13205218] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/02/2021] [Accepted: 10/08/2021] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitors are immune stimulatory drugs used to treat many types of cancer. These drugs are antibodies against inhibitory proteins, such as CTLA-4 and PD-1/PD-L1, that are expressed on immune cells. When bound, they allow for increased stimulation of T cells to fight tumor cells. However, immune checkpoint inhibitors have several immune-related adverse effects. Many cases have come to light recently of cardiotoxicity as a result of treatment with these drugs. Cardiotoxicity from immune checkpoint inhibitors is unique due to its rarity and high mortality rate. Patients with this toxicity may present with myocarditis, pericarditis, Takotsubo cardiomyopathy, conduction disorders, and others within just a few weeks of starting immune checkpoint inhibitors. We present here a review of the current research on immune checkpoint inhibitors, their associated cardiotoxicities, the timing of presentation of these conditions, lab tests and histology for each condition, and finally the treatment of patients with cardiotoxicity. We observe a positive skew in the onset of presentation, which is significant for the treating physician.
Collapse
Affiliation(s)
- Walid Shalata
- The Legacy Heritage Center & Dr. Larry Norton Institute, Soroka Medical Center, Beer Sheva 84105, Israel; (I.M.); (A.Y.)
| | - Amjad Abu-salman
- Cardiology Division, Soroka Medical Center, Beer Sheva 84105, Israel;
| | - Rachel Steckbeck
- Medical School for International Health, Ben Gurion University of the Negev, Beer Sheva 84105, Israel; (R.S.); (B.M.J.)
| | - Binil Mathew Jacob
- Medical School for International Health, Ben Gurion University of the Negev, Beer Sheva 84105, Israel; (R.S.); (B.M.J.)
| | - Ismaell Massalha
- The Legacy Heritage Center & Dr. Larry Norton Institute, Soroka Medical Center, Beer Sheva 84105, Israel; (I.M.); (A.Y.)
| | - Alexander Yakobson
- The Legacy Heritage Center & Dr. Larry Norton Institute, Soroka Medical Center, Beer Sheva 84105, Israel; (I.M.); (A.Y.)
| |
Collapse
|
31
|
Marsili L, Dal Bo M, Berti F, Toffoli G. Thermoresponsive Chitosan-Grafted-Poly( N-vinylcaprolactam) Microgels via Ionotropic Gelation for Oncological Applications. Pharmaceutics 2021; 13:1654. [PMID: 34683947 PMCID: PMC8539247 DOI: 10.3390/pharmaceutics13101654] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/23/2021] [Accepted: 09/25/2021] [Indexed: 12/19/2022] Open
Abstract
Microgels can be considered soft, porous and deformable particles with an internal gel structure swollen by a solvent and an average size between 100 and 1000 nm. Due to their biocompatibility, colloidal stability, their unique dynamicity and the permeability of their architecture, they are emerging as important candidates for drug delivery systems, sensing and biocatalysis. In clinical applications, the research on responsive microgels is aimed at the development of "smart" delivery systems that undergo a critical change in conformation and size in reaction to a change in environmental conditions (temperature, magnetic fields, pH, concentration gradient). Recent achievements in biodegradable polymer fabrication have resulted in new appealing strategies, including the combination of synthetic and natural-origin polymers with inorganic nanoparticles, as well as the possibility of controlling drug release remotely. In this review, we provide a literature review on the use of dual and multi-responsive chitosan-grafted-poly-(N-vinylcaprolactam) (CP) microgels in drug delivery and oncological applications.
Collapse
Affiliation(s)
- Lorenzo Marsili
- Department of Chemical and Pharmaceutical Sciences, University of Trieste, Via Licio Giorgieri 1, 34127 Trieste, Italy;
- Experimental and Clinical Pharmacology Unit, CRO National Cancer Institute IRCCS, Via Franco Gallini 2, 33081 Aviano, Italy; (M.D.B.); (G.T.)
| | - Michele Dal Bo
- Experimental and Clinical Pharmacology Unit, CRO National Cancer Institute IRCCS, Via Franco Gallini 2, 33081 Aviano, Italy; (M.D.B.); (G.T.)
| | - Federico Berti
- Department of Chemical and Pharmaceutical Sciences, University of Trieste, Via Licio Giorgieri 1, 34127 Trieste, Italy;
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology Unit, CRO National Cancer Institute IRCCS, Via Franco Gallini 2, 33081 Aviano, Italy; (M.D.B.); (G.T.)
| |
Collapse
|
32
|
Liu Q, Yu Y, Lin J, Wang Y, Ai L, Li Q, Wu W, Jin H, Li S, Liu M, Yu S, Liu T. Treatment strategy for myocarditis in patients using immune checkpoint inhibitors or combined anti-vascular endothelial growth factor therapy by clinical severity. Eur J Cancer 2021; 157:10-20. [PMID: 34464781 DOI: 10.1016/j.ejca.2021.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/01/2021] [Accepted: 07/22/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Combination of immune checkpoint inhibitor (ICI) and anti-vascular endothelial growth factor (VEGF) therapy has increasingly become a promising strategy in various tumors. However, the combination might be associated with increased cardiotoxicities. Myocarditis is a potentially fatal complication in cancer patients treated with ICI. Currently, there are no clear guidelines for the management of this disease nor data characterizing the clinical course of myocarditis patients due to the combination of ICI and anti-VEGF therapy. PATIENTS AND METHODS This study included all patients consecutively admitted to Shanghai Zhongshan Hospital, Fudan University for the diagnosis of ICI-associated myocarditis according to Bonaca's criteria. The clinical presentation and outcome of myocarditis patients were collected receiving ICI and anti-VEGF combined therapy. RESULTS A total of 48 patients were included (23 received combined treatment of ICI and anti-VEGF while 25 received ICI only). No differences in baseline characteristics, clinical course, and outcomes were observed among patients receiving ICI with or without anti-VEGF treatment. The patients were subdivided into 3 groups including 8 fulminant cases, 25 clinically significant cases, and 15 subclinical cases based on clinical severity. The fulminant group was associated with a higher rate of cardiovascular deaths (CVDs) compared with clinically significant and subclinical groups (87.5% versus 4.0% versus 0.0%, p < 0.01). When stratified by the dose of corticosteroids used, cases with high-dose usage were more likely to have a CVD when compared to low dose or no use and intermediate dose groups (0.0% versus 4.0% versus 57.1%, p < 0.01). CONCLUSIONS No significant differences between myocarditis patients receiving ICI or combined anti-VEGF therapy in terms of clinical presentation and outcome were observed. Treatment strategy for myocarditis in patients using ICI or combined anti-VEGF therapy should be based on clinical severity. Specifically, immunosuppressive therapy besides high-dose corticosteroids is needed for fulminant cases.
Collapse
Affiliation(s)
- Qing Liu
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Cancer Center, Zhongshan Hospital, 180 Fenglin Road, Shanghai, 200032, China
| | - Yiyi Yu
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Cancer Center, Zhongshan Hospital, 180 Fenglin Road, Shanghai, 200032, China
| | - Jinyi Lin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yan Wang
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Cancer Center, Zhongshan Hospital, 180 Fenglin Road, Shanghai, 200032, China
| | - Luoyan Ai
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Cancer Center, Zhongshan Hospital, 180 Fenglin Road, Shanghai, 200032, China
| | - Qian Li
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Cancer Center, Zhongshan Hospital, 180 Fenglin Road, Shanghai, 200032, China
| | - Wei Wu
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Hang Jin
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Suyao Li
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Mengling Liu
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Shan Yu
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Cancer Center, Zhongshan Hospital, 180 Fenglin Road, Shanghai, 200032, China
| | - Tianshu Liu
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Cancer Center, Zhongshan Hospital, 180 Fenglin Road, Shanghai, 200032, China.
| |
Collapse
|
33
|
Arangalage D, Degrauwe N, Michielin O, Monney P, Özdemir BC. Pathophysiology, diagnosis and management of cardiac toxicity induced by immune checkpoint inhibitors and BRAF and MEK inhibitors. Cancer Treat Rev 2021; 100:102282. [PMID: 34438238 DOI: 10.1016/j.ctrv.2021.102282] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/16/2022]
Abstract
Immune checkpoint inhibitors (ICIs) and BRAF and MEK inhibitors (BRAFi/MEKi) have drastically improved the outcome of melanoma patients. ICIs can induce myocarditis, a rare immune related adverse event (irAE) with an estimated lethality of 50%. BRAFi/MEKi may induce left ventricular ejection fraction decrease, hypertension or QT interval prolongation. While the BRAFi/MEKi induced cardiotoxicity is often reversible upon treatment discontinuation or dose adaptation and symptomatic therapy is often sufficient to restore cardiac function, the treatment of ICI-induced myocarditis mainly relies on high dose corticosteroids. There is no established therapy for steroid resistant myocarditis, yet various drugs have been reported to improve outcome. Shared epitopes between melanoma cells and cardiac tissue are thought to underlie the development of ICIs induced myocarditis. The mechanism of BRAFi/MEKi induced cardiotoxicity appears to be related to the Ras-Raf-MEK-ERK pathway in cardiomyocyte repair, survival and proliferation. With the emerging application of ICI-BRAFi/MEKi combinations, so called triplet therapies, differentiating between these two types of cardiotoxicity will become important for appropriate patient management. In this article we provide a summary of the existing literature on the pathophysiology, diagnosis and management of cardiotoxicity of melanoma therapies.
Collapse
Affiliation(s)
- Dimitri Arangalage
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Nils Degrauwe
- Department of Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Olivier Michielin
- Department of Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Pierre Monney
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland.
| | - Berna C Özdemir
- Department of Oncology, Bern University Hospital (Inselspital), University of Bern, Switzerland; International Cancer Prevention Institute, Epalinges, Switzerland.
| |
Collapse
|
34
|
Immune checkpoint inhibitors: An emergency medicine focused review. Am J Emerg Med 2021; 50:335-344. [PMID: 34450397 DOI: 10.1016/j.ajem.2021.08.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/16/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Several novel cancer therapies have been developed, many of which focused on immune system modulation. These include immune checkpoint inhibitors, modulators, T-cell therapy, monoclonal antibodies, cytokines, oncolytic viruses, and vaccines. Although many of these therapies are well tolerated, significant adverse reactions can occur as a result of these novel drugs. OBJECTIVE This narrative review discusses complications associated with immune based cancer therapies, specifically immune checkpoint inhibitors, for emergency clinicians. DISCUSSION Novel cancer therapies including immune checkpoint inhibitors can improve the care of patients with malignancy. However, these therapies have a number of potential complications, known as immune-related adverse events (irAEs). Complications can involve the neurologic, cardiac, pulmonary, dermatologic, renal, gastrointestinal, hepatic, and hematologic systems. IrAEs most commonly occur in the first several months following treatment initiation. These complications can be graded based on severity of clinical and laboratory findings. While most of these irAEs are mild, patients may present with critical illness. Treatment commonly includes immune checkpoint inhibitor discontinuation, steroids, and evaluation for other immunosuppressant medications. CONCLUSIONS Knowledge of this novel cancer therapy class and its potential complications can improve the care of patients on immune checkpoint inhibitors in the emergency department setting.
Collapse
|
35
|
Delombaerde D, Vervloet D, Franssen C, Croes L, Gremonprez F, Prenen H, Peeters M, Vulsteke C. Clinical implications of isolated troponinemia following immune checkpoint inhibitor therapy. ESMO Open 2021; 6:100216. [PMID: 34271309 PMCID: PMC8287144 DOI: 10.1016/j.esmoop.2021.100216] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/18/2021] [Accepted: 06/28/2021] [Indexed: 01/27/2023] Open
Abstract
Cardiovascular adverse events induced by immune checkpoint inhibitors (ICIs) have gained significant interest over the past decade due to their impact on short- and long-term outcomes. They were initially thought to be rare, but the increasing use of ICIs in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in their incidence. Different guidelines have proposed screening measures for ICI-induced myocarditis by incorporating troponin measurements at baseline and during the first few weeks of treatment. However, no specific guidelines have been developed yet regarding the interpretation of an asymptomatic rise in troponins. This state-of-the art review aims to provide an overview of the clinical relevance of elevated troponins during checkpoint inhibition and recommendations on how to manage elevated troponin levels during ICI therapy.
Collapse
Affiliation(s)
- D Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium.
| | - D Vervloet
- Department of Cardiology, AZ Maria Middelares, Ghent, Belgium
| | - C Franssen
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - L Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
| | - F Gremonprez
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - H Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - M Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - C Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
| |
Collapse
|
36
|
Lehmann LH, Cautela J, Palaskas N, Baik AH, Meijers WC, Allenbach Y, Alexandre J, Rassaf T, Müller OJ, Aras M, Asnani AH, Deswal A, Laufer-Perl M, Thuny F, Kerneis M, Hayek SS, Ederhy S, Salem JE, Moslehi JJ. Clinical Strategy for the Diagnosis and Treatment of Immune Checkpoint Inhibitor-Associated Myocarditis: A Narrative Review. JAMA Cardiol 2021; 6:1329-1337. [PMID: 34232253 DOI: 10.1001/jamacardio.2021.2241] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance In the last decade, immune checkpoint inhibitors (ICIs) have been approved for the treatment of many cancer types. Immune checkpoint inhibitor-associated myocarditis has emerged as a significant and potentially fatal adverse effect. Recognizing, diagnosing, and treating ICI-associated myocarditis poses new challenges for the practicing clinician. Here, the current literature on ICI-associated myocarditis is reviewed. Observations Clinical presentation and cardiac pathological findings are highly variable in patients with ICI-associated myocarditis. Although endomyocardial biopsy is the criterion standard diagnostic test, a combination of clinical suspicion, cardiac biomarkers (specifically troponin), and cardiac imaging, in addition to biopsy, is often needed to support the diagnosis. Importantly, the combination of a cytotoxic T-lymphocyte-associated protein 4 inhibitor with a programmed cell death protein 1 or programmed death-ligand 1 inhibitor increases the risk of developing ICI-associated myocarditis. Conclusion and Relevance This review aims to provide a standardized diagnostic and therapeutic approach for patients with suspected ICI-associated myocarditis. A complete history of recent cancer treatments and physical examination in combination with cardiac biomarkers, cardiac imaging, and endomyocardial biopsy represent a pragmatic diagnostic approach for most cases of ICI-associated myocarditis. The addition of novel biomarkers or imaging modalities is an area of active research and should be evaluated in larger cohorts.
Collapse
Affiliation(s)
- Lorenz H Lehmann
- Department of Cardiology, Angiology, and Pneumology, Cardio-Oncology Unit, Heidelberg University Hospital, Heidelberg, Germany.,German Centre for Cardiovascular Research, partner site Heidelberg/Mannheim, Heidelberg, Germany.,German Cancer Research Centre, Heidelberg, Germany
| | - Jennifer Cautela
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, France.,Groupe Méditerranéen de Cardio-Oncologie, Marseille, France.,Oncosafety Network of the Early Phases Cancer Trials Center, Marseille, France
| | - Nicolas Palaskas
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Alan H Baik
- Department of Medicine, Division of Cardiology, University of California, San Francisco
| | - Wouter C Meijers
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France.,Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Association Institut de Myologie, Centre de Recherche en Myologie, UMRS974, Paris, France
| | - Joachim Alexandre
- Department of Pharmacology, Normandie University, University of Caen Normandy, PICARO Cardio-oncology Program, Signalisation, Électrophysiologie et Imagerie des Lésions d'Ischémie-Reperfusion Myocardique, Caen, France
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver J Müller
- Department of Internal Medicine III, University of Kiel, Kiel, Germany.,German Center for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Mandar Aras
- Department of Medicine, Division of Cardiology, University of California, San Francisco
| | - Aarti H Asnani
- CardioVascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anita Deswal
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Michal Laufer-Perl
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Franck Thuny
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, France.,Groupe Méditerranéen de Cardio-Oncologie, Marseille, France
| | - Mathieu Kerneis
- Sorbonne Université, ACTION Study Group, Institut National de la Santé et de la Recherche Médicale, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Stéphane Ederhy
- Hôpitaux Universitaires Paris-Est, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Service de Cardiologie, Unico, Unité de Cardio-Oncologie, Groupe de Recherche Clinique en Cardio-Oncologie, Université Pierre et Marie Curie, Paris, France
| | - Joe-Elie Salem
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, UNICO-GRECO Cardio-Oncology Program, Pitié-Salpêtrière Hospital, Paris, France
| | - Javid J Moslehi
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
37
|
Kurzhals JK, Graf T, Boch K, Grzyska U, Frydrychowicz A, Zillikens D, Terheyden P, Langan EA. Serum Troponin T Concentrations Are Frequently Elevated in Advanced Skin Cancer Patients Prior to Immune Checkpoint Inhibitor Therapy: Experience From a Single Tertiary Referral Center. Front Med (Lausanne) 2021; 8:691618. [PMID: 34291066 PMCID: PMC8288046 DOI: 10.3389/fmed.2021.691618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/20/2021] [Indexed: 01/22/2023] Open
Abstract
Immune checkpoint inhibitor (ICI) therapy has revolutionized the treatment of several human malignancies, particularly metastatic skin cancer. However, immune-related myocarditis (irM), an immune-mediated adverse event (irAE), is often fatal. In the absence of a reliable biomarker, measurement of pre-ICI therapy serum troponin concentration has been proposed to identify patients at risk of developing irM, although real-world studies examining this strategy are lacking. Thus, we retrospectively analyzed the case records of all patients who commenced ICI therapy between January 2018 and December 2019 in a single university skin cancer center (n = 121) to (i) determine the incidence of irM, (ii) establish the frequency of pretreatment serum hsTnT elevations, and (iii) to establish whether this identified patients who subsequently developed irM. Only one patient developed irM, resulting in an overall incidence of 0.8%. Pretreatment hsTnT was measured in 47 patients and was elevated in 13 (28%). Elevated serum hsTnT concentrations were associated with chronic renal failure (p = 0.02) and diabetes (p < 0.0002). Pretreatment hsTnT was not elevated in the patient who developed fulminant irM. Pre-immunotherapy serum hsTnT concentrations were often asymptomatically elevated in patients with advanced skin cancer, none of whom subsequently developed irM during ICI therapy. However, large studies are required to assess the positive and negative predictive values of hsTnT for the development of irM. In the meantime, elevated hsTnT concentrations should be investigated before initiation of immunotherapy and closely monitored during early treatment cycles, where the risk of irM is greatest.
Collapse
Affiliation(s)
- Jonas K Kurzhals
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Tobias Graf
- Department of Cardiology, University of Lübeck, Lübeck, Germany
| | - Katharina Boch
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Ulrike Grzyska
- Department of Radiology and Nuclear Medicine, University of Lübeck, Lübeck, Germany
| | - Alex Frydrychowicz
- Department of Radiology and Nuclear Medicine, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Ewan A Langan
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Dermatological Sciences, University of Manchester, Manchester, United Kingdom
| |
Collapse
|
38
|
Ma Z, Pei J, Sun X, Liu L, Lu W, Guo Q, Lyu J, Liu Y, Zhang Y, Zhao Z. Pericardial Toxicities Associated With Immune Checkpoint Inhibitors: A Pharmacovigilance Analysis of the FDA Adverse Event Reporting System (FAERS) Database. Front Pharmacol 2021; 12:663088. [PMID: 34276364 PMCID: PMC8283181 DOI: 10.3389/fphar.2021.663088] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/18/2021] [Indexed: 01/22/2023] Open
Abstract
Introdution: Immune checkpoint inhibitors (ICIs) have significantly improved clinical outcomes for a wide range of cancers but can also lead to serious or fatal immune-related adverse events (irAEs). Although ICI-related pericardial toxicities have been reported, the clinical features are not well characterized in real-world studies. Objective: To characterize the main features of ICI-related pericardial toxicities and identify factors associated with death. Methods: Data from January 1, 2011 to March 31, 2020 in the FDA Adverse Event Reporting System database were retrieved for disproportionality analysis. We used the reporting odds ratio and the information component (IC) to evaluate the association between ICIs and pericardial adverse events. Clinical characteristics of patients with ICI-associated pericardial toxicities were collected and compared between fatal and non-fatal groups. The time to onset following different ICI regimens was further investigated. Results: We identified a total of 705 ICI-associated pericardial toxicities which appeared to influence more men (53.90%) than women (36.03%), with a median age of 63 (interquartile range [IQR] 54–69) years. Patients with lung cancer accounted for the largest proportion (55.6%). ICI therapies were detected with pharmacovigilance signals of pericardial toxicities, corresponding to IC025 = 2.11 and ROR 4.87 [4.51–5.25]. Nevertheless, there was a lack of association between anti-CTLA-4 and pericardial toxicities. There was no difference in onset time among all ICI regimens. However, TTO of fatal cases (25 days (interquartile range [IQR] 6–70)) occurred statistically earlier than non-fatal cases (42 days (IQR 12–114), p = 0.003). Conclusion: ICI monotherapy (PD-1/PD-L1 therapy) and combination therapy can lead to pericardial toxicities that can result in serious outcomes and tend to occur early. Early recognition and management of ICI-related pericardial disorders should attract clinical attention. The findings require further clinical surveillance for the quantification.
Collapse
Affiliation(s)
- Zhuo Ma
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jie Pei
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ximu Sun
- Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Lihong Liu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wenchao Lu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qixiang Guo
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jiayou Lyu
- A.I. Phoenix Technology Co., Ltd., Hong Kong, China
| | - Yuwei Liu
- A.I. Phoenix Technology Co., Ltd., Hong Kong, China
| | - Yuhui Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhixia Zhao
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
39
|
Zarifa A, Kim JW, Lopez-Mattei J, Palaskas N, Iliescu C, Kim PY. Cardiac Toxicities Associated with Immune Checkpoints Inhibitors: Mechanisms, Manifestations and Management. Korean Circ J 2021; 51:579-597. [PMID: 34227272 PMCID: PMC8263294 DOI: 10.4070/kcj.2021.0089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/02/2021] [Accepted: 05/07/2021] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) associated cardiovascular adverse events (CVAE) have become more frequent with the growing use of cancer immunotherapy. CVAEs include a wide spectrum of diseases such as myocarditis, pericarditis, heart failure, arrhythmias, coronary artery disease, and hypertension. The induction of cardiovascular side effects by ICI use is hypothesized to occur due to inflammation and immune dysregulation of normal tissue in response to immunotherapy. Management of ICI-associated CVAEs mitigates an overactive immune response by utilizing steroids, immunomodulatory drugs and hemodynamic stabilization. However, few controlled studies on the cardiovascular safety of ICIs exist and treatment of their side effects are mostly from limited case series. Our review seeks to provide the most recent understanding of ICI-associated CVAEs and their management.
Collapse
Affiliation(s)
- Abdulrazzak Zarifa
- Department of Medicine, Brookdale Hospital University and Medical Center, Brooklyn, NY, USA
| | - Jin Wan Kim
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Juan Lopez-Mattei
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicolas Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cezar Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter Y Kim
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
40
|
Hu J, Tian R, Ma Y, Zhen H, Ma X, Su Q, Cao B. Risk of Cardiac Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Regimens: A Systematic Review and Meta-Analysis. Front Oncol 2021; 11:645245. [PMID: 34123795 PMCID: PMC8190385 DOI: 10.3389/fonc.2021.645245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
Background We performed a systematic review and meta-analysis to evaluate the risks of cardiac adverse events in solid tumor patients treated with monotherapy of immune checkpoint inhibitors (ICIs) or combined therapy of ICIs plus chemotherapy. Methods Eligible studies were selected through the following databases: PubMed, Embase and clinical trials (https://clinicaltrials.gov.) and included phase III/IV randomized controlled trials (RCTs) involving patients with the solid tumor treated with ICIs. The data was analyzed by using Review Manager (version5.3), Stata (version 15.1). Results Among 2,551 studies, 25 clinical trials including 20,244 patients were qualified for the meta-analysis. Compared with PD-1 inhibitor (nivolumab) or CTLA-4 inhibitor (ipilimumab), PD-1 inhibitor (nivolumab) plus CTLA-4 inhibitor (ipilimumab) combined therapy showed significant increase in grade 5 arrhythmology (OR 3.90, 95% CI: 1.08–14.06, p = 0.603). PD-1 inhibitor plus chemotherapy show significant increase in grades 1–5 myocardial disease (OR 5.09, 95% CI: 1.11–23.32, p = 1.000). Compared with chemotherapy, PD-1 inhibitor (nivolumab) or CTLA-4 inhibitor (ipilimumab), PD-1 inhibitor (nivolumab) plus CTLA-4 inhibitor (ipilimumab) combined therapy show significant increase in grades 1–5 arrhythmology (OR 2.49, 95% CI: 1.30–4.78, p = 0.289). Conclusions Our meta-analysis demonstrated that PD-1 inhibitor plus CTLA-4 inhibitor can result in a higher risk of grade 5 arrhythmology in comparison with PD-1/CTLA-4 inhibitor alone, and a higher risk of grade 5 arrhythmology in comparison with chemotherapy. PD-1 inhibitor plus chemotherapy treatment could increase the risk of all-grade myocardial disease compared with chemotherapy. However, in most cases, there was no significant increase of risks of cardiovascular toxicity in PD-1/PD-L1 inhibitor monotherapy or PD-1/PD-L1 inhibitor plus chemotherapy compared with chemotherapy alone.
Collapse
Affiliation(s)
- Jiexuan Hu
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ruyue Tian
- Department of Ultrasound, Aero Space Central Hospital, Beijing, China
| | - Yingjie Ma
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hongchao Zhen
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiao Ma
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qiang Su
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Bangwei Cao
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
41
|
Gong FF, Cascino GJ, Murtagh G, Akhter N. Circulating Biomarkers for Cardiotoxicity Risk Prediction. Curr Treat Options Oncol 2021; 22:46. [PMID: 33866434 DOI: 10.1007/s11864-021-00845-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 01/22/2023]
Abstract
OPINION STATEMENT Improvements in cancer survival have led to the emergence of cardiovascular disease as an important determinant of adverse outcome in survivors. Cancer therapeutics-related cardiac dysfunction is the most well-known form of cardiotoxicity. However, newer cancer therapies bring a broader range of cardiotoxicities. The optimal method to identify patients at risk of these complications is unclear, but circulating biomarkers comprise one possible approach. Troponins and natriuretic peptides have garnered the broadest evidence base for cardiotoxicity risk prediction, but other markers are being investigated. In this review, we explore evidence for circulating biomarkers in cardiotoxicity prediction associated with cancer therapies.
Collapse
Affiliation(s)
- Fei Fei Gong
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 600, Chicago, IL, 60611, USA
| | - Gregory J Cascino
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 600, Chicago, IL, 60611, USA
| | - Gillian Murtagh
- Diagnostics Division, Abbott Laboratories, 100 Abbott Park Road, CP1-3, Abbott Park, North Chicago, IL, 60064-6094, USA
| | - Nausheen Akhter
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 600, Chicago, IL, 60611, USA.
| |
Collapse
|
42
|
Poto R, Marone G, Pirozzi F, Galdiero MR, Cuomo A, Formisano L, Bianco R, Della Corte CM, Morgillo F, Napolitano S, Troiani T, Tocchetti CG, Mercurio V, Varricchi G. How can we manage the cardiac toxicity of immune checkpoint inhibitors? Expert Opin Drug Saf 2021; 20:685-694. [PMID: 33749484 DOI: 10.1080/14740338.2021.1906860] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Cancer immunotherapies with monoclonal antibodies (mAbs) against immune checkpoints (i.e. CTLA-4 and PD-1/PD-L1) have revolutionized antineoplastic treatments. Immune checkpoint inhibitors (ICIs) approved for cancer immunotherapy are mAbs anti-CTLA-4 (ipilimumab), anti-PD-1 (nivolumab, pembrolizumab, and cemiplimab), and anti-PD-L1 (atezolizumab, avelumab, and durvalumab). Treatment with ICIs can be associated with immune-related adverse events (irAEs), including an increased risk of developing myocarditis. These findings are compatible with the observation that, CTLA-4, PD-1, and PD-L1 pathways play a central role in the modulation of autoimmunity.Areas covered: In this paper, we start from examining the pathogenesis of cardiovascular adverse events from ICIs, and then we focus on risk factors and strategies to prevent and manage this cardiotoxicity.Expert opinion: There is a growing need for a multidisciplinary approach of ICI-associated cardiotoxicity, involving oncologists, cardiologists, and immunologists. Prevention and effective management of ICIs cardiotoxicity starts with an in-depth screening and surveillance strategies of high-risk patients, in order to improve early detection and appropriate management in a personalized approach.
Collapse
Affiliation(s)
- Remo Poto
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Giancarlo Marone
- Department of Public Health, Section of Hygiene, University of Naples Federico II, Naples, Italy.,Monaldi Hospital Pharmacy, Naples, Italy
| | - Flora Pirozzi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Maria Rosaria Galdiero
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| | - Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Luigi Formisano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.,Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | - Roberto Bianco
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.,Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | | | - Floriana Morgillo
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Stefania Napolitano
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Teresa Troiani
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy.,Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| |
Collapse
|
43
|
Zhang RS, Padegimas A, Murphy KM, Evans PT, Peters CJ, Domenico CM, Vidula MK, Mather PJ, Cevasco M, Cohen RB, Carver JR, O'Quinn RP. Treatment of corticosteroid refractory immune checkpoint inhibitor myocarditis with Infliximab: a case series. CARDIO-ONCOLOGY 2021; 7:13. [PMID: 33785062 PMCID: PMC8008661 DOI: 10.1186/s40959-021-00095-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 02/07/2021] [Indexed: 12/22/2022]
Abstract
Background Glucocorticoid treatment remains the cornerstone of therapy for immune checkpoint inhibitor (ICI) myocarditis, but data supporting the use of additional immunotherapy for steroid refractory cases remains limited. We investigate the safety and efficacy of infliximab in patients with ICI myocarditis who are refractory to corticosteroids. Additionally, we highlight the importance of a multi-disciplinary approach in the care for these complex patients. Methods We retrospectively identified consecutive patients who developed ICI myocarditis at our institution between January 2017 and January 2020. Baseline characteristics, laboratory data and clinical outcomes were compared between patients who received infliximab and those who did not. Results Of a total of 11 patients who developed ICI myocarditis, 4 were treated with infliximab. Aside from age, there were no significant differences in baseline patient characteristics between the two groups including total number of ICI doses received and duration from initial ICI dose to onset of symptoms. The time to troponin normalization was 58 vs. 151.5 days (p = 0.25). The duration of prednisone taper was longer in the infliximab group (90 vs. 150 days p = 0.32). All patients survived initial hospital admission. Over a median follow-up period of 287 days, two of the 4 patients died from sepsis 2 and 3 months after initial treatment of their myocarditis; one of these patients was on a steroid taper and the other patient had just completed a steroid taper. Conclusions Infliximab, despite its black box warning in patients with heart failure, may be a safe and effective treatment for ICI myocarditis.
Collapse
Affiliation(s)
- Robert S Zhang
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Allison Padegimas
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Kathleen M Murphy
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Infectious Disease, University of Pennsylvania, PA, Philadelphia, USA
| | - Peter T Evans
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Carli J Peters
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | | | - Mahesh K Vidula
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Paul J Mather
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Marisa Cevasco
- Department of Cardiothoracic Surgery, University of Pennsylvania, PA, Philadelphia, USA
| | - Roger B Cohen
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Hematology-Oncology, University of Pennsylvania, PA, Philadelphia, USA
| | - Joseph R Carver
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Hematology-Oncology, University of Pennsylvania, PA, Philadelphia, USA
| | - Rupal P O'Quinn
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA. rupal.o'.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA. rupal.o'
| |
Collapse
|
44
|
Jimbu L, Mesaros O, Popescu C, Neaga A, Berceanu I, Dima D, Gaman M, Zdrenghea M. Is There a Place for PD-1-PD-L Blockade in Acute Myeloid Leukemia? Pharmaceuticals (Basel) 2021; 14:288. [PMID: 33804850 PMCID: PMC8063836 DOI: 10.3390/ph14040288] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 02/07/2023] Open
Abstract
Checkpoint inhibitors were a major breakthrough in the field of oncology. In September 2014, based on the KEYNOTE-001 study, the Food and Drug Administration (FDA) approved pembrolizumab, a programmed cell death protein 1 (PD-1) inhibitor, for advanced or unresectable melanoma. Up until now, seven PD-1/PD-ligand(L)-1 inhibitors are approved in various solid cancers and hundreds of clinical studies are currently ongoing. In hematology, PD-1 inhibitors nivolumab and pembrolizumab were approved for the treatment of relapsed/refractory (R/R) classic Hodgkin lymphoma, and later pembrolizumab was approved for R/R primary mediastinal large B-cell lymphoma. In acute myeloid leukemia (AML), the combination of hypomethylating agents and PD-1/PD-L1 inhibitors has shown promising results, worth of further investigation, while other combinations or single agent therapy have disappointing results. On the other hand, rather than in first line, these therapies could be useful in the consolidation or maintenance setting, for achieving minimal residual disease negativity. Furthermore, an interesting application could be the use of PD-1/PD-L1 inhibitors in the post allogeneic hematopoietic stem cell transplantation relapse. There are several reasons why checkpoint inhibitors are not very effective in treating AML, including the characteristics of the disease (systemic, rapidly progressive, and high tumor burden disease), low mutational burden, and dysregulation of the immune system. We here review the results of PD-1/PD-L1 inhibition in AML and discuss their potential future in the management of this disease.
Collapse
Affiliation(s)
- Laura Jimbu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Babes Str., 400012 Cluj-Napoca, Romania; (O.M.); (C.P.); (A.N.); (M.Z.)
- Department of Hematology, Ion Chiricuta Oncology Institute, 34-36 Republicii Str., 400015 Cluj-Napoca, Romania; (I.B.); (D.D.)
| | - Oana Mesaros
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Babes Str., 400012 Cluj-Napoca, Romania; (O.M.); (C.P.); (A.N.); (M.Z.)
- Department of Hematology, Ion Chiricuta Oncology Institute, 34-36 Republicii Str., 400015 Cluj-Napoca, Romania; (I.B.); (D.D.)
| | - Cristian Popescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Babes Str., 400012 Cluj-Napoca, Romania; (O.M.); (C.P.); (A.N.); (M.Z.)
- Department of Infectious Diseases, County Emergency Hospital Alba Iulia, 20 Decebal Str., 510093 Alba-Iulia, Romania
| | - Alexandra Neaga
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Babes Str., 400012 Cluj-Napoca, Romania; (O.M.); (C.P.); (A.N.); (M.Z.)
| | - Iulia Berceanu
- Department of Hematology, Ion Chiricuta Oncology Institute, 34-36 Republicii Str., 400015 Cluj-Napoca, Romania; (I.B.); (D.D.)
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Oncology Institute, 34-36 Republicii Str., 400015 Cluj-Napoca, Romania; (I.B.); (D.D.)
| | - Mihaela Gaman
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Mihnea Zdrenghea
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Babes Str., 400012 Cluj-Napoca, Romania; (O.M.); (C.P.); (A.N.); (M.Z.)
- Department of Hematology, Ion Chiricuta Oncology Institute, 34-36 Republicii Str., 400015 Cluj-Napoca, Romania; (I.B.); (D.D.)
| |
Collapse
|
45
|
Moslehi J, Lichtman AH, Sharpe AH, Galluzzi L, Kitsis RN. Immune checkpoint inhibitor-associated myocarditis: manifestations and mechanisms. J Clin Invest 2021; 131:145186. [PMID: 33645548 DOI: 10.1172/jci145186] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have transformed the treatment of various cancers, including malignancies once considered untreatable. These agents, however, are associated with inflammation and tissue damage in multiple organs. Myocarditis has emerged as a serious ICI-associated toxicity, because, while seemingly infrequent, it is often fulminant and lethal. The underlying basis of ICI-associated myocarditis is not completely understood. While the importance of T cells is clear, the inciting antigens, why they are recognized, and the mechanisms leading to cardiac cell injury remain poorly characterized. These issues underscore the need for basic and clinical studies to define pathogenesis, identify predictive biomarkers, improve diagnostic strategies, and develop effective treatments. An improved understanding of ICI-associated myocarditis will provide insights into the equilibrium between the immune and cardiovascular systems.
Collapse
Affiliation(s)
- Javid Moslehi
- Division of Cardiovascular Medicine and Division of Oncology, Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew H Lichtman
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Arlene H Sharpe
- Department of Immunology and Blavatnik Institute, Harvard Medical School, Boston, Massachusetts, USA.,Evergrande Center for Immunologic Diseases, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lorenzo Galluzzi
- Department of Radiation Oncology, Sandra and Edward Meyer Cancer Center, Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medical College, New York, New York, USA.,Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA.,Université de Paris, Paris, France
| | - Richard N Kitsis
- Departments of Medicine and Cell Biology, Wilf Family Cardiovascular Research Institute, and Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|
46
|
Kumar K, Przybylowicz R, Nazer B, Stecker EC, Henrikson CA, Masri A. Sinus Arrest and Cardiogenic Shock Precipitated by Immune Checkpoint Inhibitors. JACC: CARDIOONCOLOGY 2020; 2:810-814. [PMID: 34396299 PMCID: PMC8352114 DOI: 10.1016/j.jaccao.2020.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/28/2020] [Indexed: 12/02/2022]
Key Words
- ECG, electrocardiogram
- FT4, free T4
- ICI, immune checkpoint inhibitor
- IV, intravenous
- LAFB, left anterior fascicular block
- NSTEMI, non–ST-segment elevation myocardial infarction
- RBBB, right bundle branch block
- RCC, renal cell carcinoma
- TSH, thyroid-stimulating hormone
- TTE, transthoracic echocardiogram
- WMA, wall motion abnormality
- cardio-oncology
- cardiotoxicity
- clinical cardiology
- electrophysiology
- hypothyroidism
- immune checkpoint inhibitor
- irAE, immune-related adverse event
Collapse
Affiliation(s)
- Kris Kumar
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Ryle Przybylowicz
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Eric C Stecker
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Charles A Henrikson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Ahmad Masri
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| |
Collapse
|
47
|
Yeung SJ, Qdaisat A, Chaftari P, Lipe D, Merlin J, Rajha E, Wechsler A, Sandoval M, Viets J, Al‐Breiki A, Shah M, Pandey R, Kamal M, Khattab O, Toale K, Wattana M, Elsayem A, Gaeta S, Brock P, Reyes‐Gibby C, Alagappan K. Diagnosis and management of immune-related adverse effects of immune checkpoint therapy in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1637-1659. [PMID: 33392573 PMCID: PMC7771833 DOI: 10.1002/emp2.12209] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 12/14/2022] Open
Abstract
Rapid advances in cancer immunotherapy using immune checkpoint inhibitors have led to significantly improved survival. Rapid identification of the toxicity syndromes associated with these therapeutic agents is very important for emergency physicians because the population of patients diagnosed with cancer is increasing and cancer therapies including immune checkpoint inhibitors have become the first-line treatment for more and more types of cancer. The emergency medicine literature lags behind rapid advances in oncology, and oncology guidelines for rapid recognition and management of these emerging toxicity syndromes are not familiar to emergency physicians. In this review article, we discuss the clinical presentation and management of immune-related adverse effects during the critical first hours of emergency care. We also suggest a workflow for the recognition and treatment of emergencies arising from serious immune-related adverse effects, including but not limited to colitis, adrenal crisis, myocarditis, pneumonitis, myasthenic crisis, diabetic ketoacidosis, bullous pemphigus, and hemophagocytic lymphohistiocytosis. Rapid advances in cancer therapy are bringing new diagnostic and therapeutic challenges to emergency providers, and therefore it is crucial to raise awareness and provide guidelines for the management of new treatment-related toxicities.
Collapse
Affiliation(s)
- Sai‐Ching Jim Yeung
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Aiham Qdaisat
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Patrick Chaftari
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Demis Lipe
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Jeffrey Merlin
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Eva Rajha
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Adriana Wechsler
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Marcelo Sandoval
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Jayne Viets
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Aisha Al‐Breiki
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Mohsin Shah
- Center for Clinical Epidemiology and BiostatisticsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ramesh Pandey
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Mona Kamal
- Department of Symptom ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Clinical Oncology and Nuclear MedicineFaculty of MedicineAin Shams UniversityCairoEgypt
| | - Osama Khattab
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Katy Toale
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Monica Wattana
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ahmed Elsayem
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Susan Gaeta
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Patricia Brock
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Cielito Reyes‐Gibby
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Kumar Alagappan
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| |
Collapse
|
48
|
Romitan DM, Rădulescu D, Berindan-Neagoe I, Stoicescu L, Grosu A, Rădulescu L, Gulei D, Ciuleanu TE. Cardiomyopathies and Arrhythmias Induced by Cancer Therapies. Biomedicines 2020; 8:biomedicines8110496. [PMID: 33198152 PMCID: PMC7696637 DOI: 10.3390/biomedicines8110496] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/17/2022] Open
Abstract
Cardiology and oncology are two fields dedicated to the study of various types of oncological and cardiac diseases, but when they collide, a new specialty is born, i.e., cardio-oncology. Continuous research on cancer therapy has brought into the clinic novel therapeutics that have significantly improved patient survival. However, these therapies have also been associated with adverse effects that can impede the proper management of oncological patients through the necessity of drug discontinuation due to life-threatening or long-term morbidity risks. Cardiovascular toxicity from oncological therapies is the main issue that needs to be solved. Proper knowledge, interpretation, and management of new drugs are key elements for developing the best therapeutic strategies for oncological patients. Upon continuous investigations, the profile of cardiotoxicity events has been enlarged with the inclusion of myocarditis upon administration of immune checkpoint inhibitors and cardiac dysfunction in the context of cytokine release syndrome with chimeric antigen receptor T cell therapy. Affinity enhanced and chimeric antigen receptor T cells have both been associated with hypotension, arrhythmia, and left ventricular dysfunction, typically in the setting of cytokine release syndrome. Therefore, the cardiologist must adhere to the progressing field of cancer therapy and become familiar with the adverse effects of novel drugs, and not only the ones of standard care, such as anthracycline, trastuzumab, and radiation therapy. The present review provides essential information summarized from the latest studies from cardiology, oncology, and hematology to bring together the three specialties and offers proper management options for oncological patients.
Collapse
Affiliation(s)
- Dragoș-Mihai Romitan
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
- Correspondence:
| | - Dan Rădulescu
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
| | - Ioana Berindan-Neagoe
- Research Center for Functional Genomic, Biomedicine and Translational Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400139 Cluj-Napoca, Romania;
| | - Laurențiu Stoicescu
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
| | - Alin Grosu
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
| | - Liliana Rădulescu
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
| | - Diana Gulei
- Research Center for Advanced Medicine-Medfuture, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, 400139 Cluj-Napoca, Romania;
| | - Tudor-Eliade Ciuleanu
- Department of Chemotherapy, Ion Chiricuta Clinical Cancer Center, 400139 Cluj Napoca, Romania;
| |
Collapse
|
49
|
Sato T, Nakamori S, Watanabe S, Nishikawa K, Inoue T, Imanaka-Yoshida K, Ishida M, Sakuma H, Ito M, Dohi K. Monitoring of the Evolution of Immune Checkpoint Inhibitor Myocarditis With Cardiovascular Magnetic Resonance. Circ Cardiovasc Imaging 2020; 13:e010633. [PMID: 33153280 DOI: 10.1161/circimaging.120.010633] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Toru Sato
- Department of Cardiology and Nephrology (T.S., S.N., M. Ito, K.D.), Mie University Graduate School of Medicine, Tsu, Japan
| | - Shiro Nakamori
- Department of Cardiology and Nephrology (T.S., S.N., M. Ito, K.D.), Mie University Graduate School of Medicine, Tsu, Japan
| | - Susumu Watanabe
- Department of Urology (S.W., K.N., T.I.), Mie University Graduate School of Medicine, Tsu, Japan
| | - Kohei Nishikawa
- Department of Urology (S.W., K.N., T.I.), Mie University Graduate School of Medicine, Tsu, Japan
| | - Takahiro Inoue
- Department of Urology (S.W., K.N., T.I.), Mie University Graduate School of Medicine, Tsu, Japan
| | - Kyoko Imanaka-Yoshida
- Department of Pathology (K.I.-Y.), Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaki Ishida
- Department of Radiology (M. Ishida, H.S.), Mie University Graduate School of Medicine, Tsu, Japan
| | - Hajime Sakuma
- Department of Radiology (M. Ishida, H.S.), Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology (T.S., S.N., M. Ito, K.D.), Mie University Graduate School of Medicine, Tsu, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology (T.S., S.N., M. Ito, K.D.), Mie University Graduate School of Medicine, Tsu, Japan
| |
Collapse
|
50
|
Dolladille C, Ederhy S, Allouche S, Dupas Q, Gervais R, Madelaine J, Sassier M, Plane AF, Comoz F, Cohen AA, Thuny FR, Cautela J, Alexandre J. Late cardiac adverse events in patients with cancer treated with immune checkpoint inhibitors. J Immunother Cancer 2020; 8:jitc-2019-000261. [PMID: 31988143 PMCID: PMC7057417 DOI: 10.1136/jitc-2019-000261] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2019] [Indexed: 12/17/2022] Open
Abstract
Background Immune checkpoint inhibitor (ICI)-associated early cardiac adverse events (CAEs), mostly acute and fulminant myocarditis, have been well characterized and mainly occur during the first 90 days after ICI therapy initiation. ICI-associated late CAEs (occurring after the first 90 days of treatment) have not yet been described. Methods First, we compared characteristics of a cohort involving early (defined as a CAE time to onset (TTO) of <90 days after ICI therapy initiation) and late (defined as a CAE TTO of ≥90 days after ICI therapy initiation) ICI-associated CAE consecutive cases who were referred to three French cardio-oncology units. Second, ICI-associated CAE cases were searched in VigiBase, the WHO global individual case safety report database, and early and late ICI-associated CAEs were compared. Results In the cohort study, compared with early CAE cases (n=19, median TTO of 14 days), late ICI-associated CAE cases (n=19, median TTO of 304 days) exhibited significantly more left ventricular systolic dysfunction (LVSD) and heart failure (HF) and less frequent supraventricular arrhythmias. In VigiBase, compared with early cases (n=437, 73.3%, median TTO 21 days), the late ICI-associated CAE reports (n=159, 26.7%, median TTO 178 days) had significantly more frequent HF (21.1% vs 31.4%, respectively, p=0.01). Early and late ICI-associated CAE cases had similarly high mortality rates (40.0% vs 44.4% in the cohort and 30.0% vs 27.0% in VigiBase, respectively). Conclusions Late CAEs could occur with ICI therapy and were mainly revealed to be HF with LVSD. Trial registration numbers NCT03678337, NCT03882580, and NCT03492528.
Collapse
Affiliation(s)
- Charles Dolladille
- CHU de Caen, PICARO Cardio-oncology Program, Department of Pharmacology, CHU de Caen, Caen, France .,CHU de Caen, Department of Cardiology, CHU de Caen, Caen F-14000, France
| | - Stephane Ederhy
- Department of Cardiology, Cardio-oncology Unit, Cardio-oncology Research G, INSERM U 856, Thrombose, Athérothrombose et Pharmacologie Appliquée, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Stéphane Allouche
- EA4650, Signalisation, Électrophysiologie et Imagerie des Lésions d'Ischémie-reperfusion Myocardique, Université de Caen Normandie, Caen, Normandie, France
| | - Querntin Dupas
- EA4650, Signalisation, Électrophysiologie et Imagerie des Lésions d'Ischémie-reperfusion Myocardique, Université de Caen Normandie, Caen, Normandie, France
| | - Radj Gervais
- Onco-pneumology, Centre François Baclesse Centre de Lutte Contre le Cancer, Caen, France
| | | | - Marion Sassier
- CHU de Caen, PICARO Cardio-oncology Program, Department of Pharmacology, CHU de Caen, Caen, France
| | - Anne-Flore Plane
- CHU de Caen, Department of Cardiology, CHU de Caen, Caen F-14000, France
| | | | - Ariel Aron Cohen
- Department of Cardiology, Cardio-oncology Unit, Cardio-oncology Research G, INSERM U 856, Thrombose, Athérothrombose et Pharmacologie Appliquée, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Franck Roland Thuny
- Mediterranean University Cardio-oncology Center (MEDI-CO Center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, Marseille, APHM, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Jennifer Cautela
- Mediterranean University Cardio-oncology Center (MEDI-CO Center), Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Hôpital Nord, Marseille, APHM, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Joachim Alexandre
- CHU de Caen, PICARO Cardio-oncology Program, Department of Pharmacology, CHU de Caen, Caen, France.,EA4650, Signalisation, Électrophysiologie et Imagerie des Lésions d'Ischémie-reperfusion Myocardique, Université de Caen Normandie, Caen, Normandie, France
| |
Collapse
|