Hepatotoxicity and Recurrent NSTEMI While on Pembrolizumab for Metastatic Giant Cell Bone Tumor

Thrombotic events associated with immune checkpoint inhibitors and novel antithrombotic strategies to mitigate bleeding risk

Although immunotherapy is expanding treatment options for cancer patients, the prognosis of advanced cancer remains poor, and these patients must contend with both cancers and cancer-related thrombotic events. In particular, immune checkpoint inhibitors are associated with an increased risk of atherosclerotic thrombotic events. Given the fundamental role of platelets in atherothrombosis, co-administration of antiplatelet agents is always indicated. Platelets are also involved in all steps of cancer progression. Classical antithrombotic drugs can cause inevitable hemorrhagic side effects due to blocking integrin β3 bidirectional signaling, which regulates simultaneously thrombosis and hemostasis. Meanwhile, many promising new targets are emerging with minimal bleeding risk and desirable anti-tumor effects. This review will focus on the issue of thrombosis during immune checkpoint inhibitor treatment and the role of platelet activation in cancer progression as well as explore the mechanisms by which novel antiplatelet therapies may exert both antithrombotic and antitumor effects without excessive bleeding risk.

Effect of chemotherapy in tumor on coronary arteries: Mechanisms and management

Coronary artery disease (CAD) is an important contributor to the cardiovascular burden in cancer survivors. The development of coronary ischemia events, myocardial infarction, and heart failure has been associated with many conventional chemotherapeutic agents, new targeted therapies, and immunotherapy. The most frequent pathological manifestations of chemotherapy-mediated coronary damage include acute vasospasm, acute thrombosis, accelerated atherosclerosis development, and microvascular dysfunction. Potential screening techniques for CAD patients include baseline risk factor evaluation, polygenic risk factors, and coronary artery calcium scores. Determining the risk requires consideration of both the type of chemotherapy and the type of cancer being treated. Cardiology-oncology guidelines offer some suggestions for the care of coronary artery disease, which might involve medication, lifestyle changes, and coronary revascularization.

Interplay between acute coronary syndromes and cancer: insights into pathophysiology, diagnostic challenges, and treatment options

Acute coronary syndromes (ACS) and cancer are among the leading causes of death worldwide. In recent years, increasing evidence has suggested an interplay between these 2 conditions. This article reviews the pathophysiology, diagnostic challenges, and treatment options for ACS and cancer. The interplay between these conditions may be due to environmental, genetic, and metabolic factors. For example, smoking, hypertension, and obesity are risk factors for both ACS and cancer. Diagnosis of ACS and cancer can be challenging because the symptoms of these conditions often overlap. For example, chest pain can be a symptom of both ACS and a neoplasms. Treatment options for ACS and cancer are varied and depend on the type of disease, stage of disease, and individual patient factors. Treatment for ACS may include angioplasty, stenting, or medication therapy. Treatment for cancer may include surgical removal of the tumour, radiation therapy, or chemotherapy.

An unusual case of checkpoint-inhibitor-induced pleuropericarditis

INTRODUCTION

Pembrolizumab is an immune checkpoint inhibitor that promotes effector T-cell functions on malignant cells by binding to programmed cell death protein 1 (PD-1). Pembrolizumab is well tolerated in most cases with an adverse event profile consisting mainly of pruritus, fatigue, and anorexia. Cardiotoxicity comprises 1% of the total adverse events.

CASE REPORT

We present a case of a 64-year-old female with non-small cell lung cancer (NSCLC) who developed pleuropericarditis following pembrolizumab therapy.

MANAGEMENT & OUTCOME

The patient was successfully managed with colchicine, furosemide, and timely initiation of methylprednisolone with the improvement of her symptoms. The decision to discontinue pembrolizumab was made, and six months after this intervention, the patient has remained asymptomatic.

DISCUSSION

Clinicians should recognize these potential immune-mediated adverse effects to provide effective and timely management and optimize patient care.

An Increased Understanding of the Association Between Atherosclerosis and Immune Checkpoint Inhibitors

PURPOSE OF REVIEW

Immune checkpoint inhibitor (ICI) therapy activates the host immune system to promote tumor cell death. This activation of the immune system can lead to off-target immune-related adverse events (irAEs). There is an established link between inflammation and atherosclerosis. The purpose of this manuscript is to review the existing body of literature discussing the potential association between ICI treatment and atherosclerosis.

RECENT FINDINGS

Pre-clinical studies suggest that ICI therapy may lead to T-cell-mediated progression of atherosclerosis. Recent retrospective clinical studies have shown higher rates of myocardial infarction and stroke with ICI therapy, particularly in patients with pre-existing cardiovascular risk factors. Additionally, small observational cohort studies have used imaging modalities to demonstrate higher rates of atherosclerotic progression with ICI treatment. Early pre-clinical and clinical evidence suggests an association between ICI treatment and the progression of atherosclerosis. However, these findings are preliminary, and adequately powered prospective studies are needed to demonstrate a conclusive association. As ICI therapy is increasingly used to treat a variety of solid tumors, it is important to evaluate and mitigate the potential adverse atherosclerotic effects of ICI treatment.

PD-1/PD-L1 Blockade Accelerates the Progression of Atherosclerosis in Cancer Patients

PD-1(programed death-1)/PD-L1(programed death-1 ligand) blockade represents a major breakthrough of anti-cancer therapies, however, it may come with increased risk of cardiovascular morbidity, such as myocarditis, acute coronary syndrome, arrhythmias, etc. Although the PD-1/PD-L1-blockade-related acute coronary syndrome (ACS) is rare, it can be fatal. Previous studies have implicated a role of the PD-1/PD-L1 axis in the development of atherosclerosis. This review explores a hypothesis that PD-1/PD-L1 blockade accelerates the progression of atherosclerosis and promotes plaque rupture, by synthesizing the evidence of vascular inflammation, as well as plaque progression, destabilization and rupture via T-cell activation and effector function. In order to improve the prognosis of cancer patients and decrease the cardiotoxicity of PD-1/PD-L1 blockade therapy, early recognition of PD-1/PD-L1-blockade-related ACS is important.

Incidence rate and treatment strategy of immune checkpoint inhibitor mediated hepatotoxicity: A systematic review

Background

A hepatic adverse event (HAE) is defined as a liver injury that occurs following immune checkpoint inhibitor (ICI) administration in oncology Patients. Immune-mediated hepatotoxicity (IMH) is a type of HAE directly caused by ICI and is associated with immune system hyperactivation. HAE incidence varies across different clinical studies. This study aimed to explore the risk factors of HAE and establish a personalized IMH treatment strategy.

Methods

Randomized controlled trials (RCTs) on ICIs and case reports related to IMH were collected and summarized separately. Meta-analysis was performed using Review Manager (version 5.0), whereas correlation analysis and linear regression were performed using SPSS (version 24.0) to evaluate any correlations between the two variables.

Results

Overall, 36 RCTs containing 18,515 patients and 39 case reports met our inclusion criteria. The ICI administration increased the HAE risk (risk ratio [RR] ​= ​1.40) as well as severe HAE (RR ​= ​2.55). The overall HAE incidence and severe incidence were about 15.3% and 4.3%, respectively. Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors have a higher incidence of HAE than programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1) inhibitors. Finally, we found a positive correlation between the onset time of IMH and the recovery time of liver injury.

Conclusions

ICI administration increased the incidence risk of HAE, especially in patients treated with CTLA-4 inhibitors. Regarding IMH treatment, the glucocorticoid dosage must be individually reduced according to the severity and onset time of HAE.

Atherosclerosis With Immune Checkpoint Inhibitor Therapy: Evidence, Diagnosis, and Management: JACC: CardioOncology State-of-the-Art Review

As the clinical applications of immune checkpoint inhibitors (ICIs) expand, our knowledge of the potential adverse effects of these drugs continues to broaden. Emerging evidence supports the association between ICI therapy with accelerated atherosclerosis and atherosclerotic cardiovascular (CV) events. We discuss the biological plausibility and the clinical evidence supporting an effect of inhibition of these immune checkpoints on atherosclerotic CV disease. Further, we provide a perspective on potential diagnostic and pharmacological strategies to reduce atherosclerotic risk in ICI-treated patients. Our understanding of the pathophysiology of ICI-related atherosclerosis is in its early stages. Further research is needed to identify the mechanisms linking ICI therapy to atherosclerosis, leverage the insight that ICI therapy provides into CV biology, and develop robust approaches to manage the expanding cohort of patients who may be at risk for atherosclerotic CV disease.

Cardiac Toxicity Associated with Immune Checkpoint Inhibitors: A Systematic Review

Immune checkpoint inhibitors (ICIs) are an important advancement in the field of cancer treatment, significantly improving the survival of patients with a series of advanced malignancies, like melanoma, non-small cell lung cancer (NSCLC), hepatocellular carcinoma (HCC), renal cell carcinoma (RCC), and Hodgkin lymphoma. ICIs act upon T lymphocytes and antigen-presenting cells, targeting programmed cell death protein 1 (PD1), programmed cell death protein ligand 1 (PD-L1), and cytotoxic T-lymphocyte antigen 4 (CTLA-4), breaking the immune tolerance of the T cells against malignant cells and enhancing the body's own immune response. A variety of cardiac-adverse effects are associated with ICI-based treatment, including pericarditis, arrhythmias, cardiomyopathy, and acute coronary syndrome, with myocarditis being the most studied due to its often-unexpected onset and severity. Overall, Myocarditis is rare but presents an immune-related adverse event (irAE) that has a high fatality rate. Considering the rising number of oncological patients treated with ICIs and the severity of their potential adverse effects, a good understanding and continuous investigation of cardiac irAEs is of the utmost importance. This systematic review aimed to revise recent publications (between 2016-2022) on ICI-induced cardiac toxicities and highlight the therapeutical approach and evolution in the selected cases.

Cardiotoxicity associated with immune checkpoint inhibitors: Current status and future challenges

Immune checkpoint inhibitors (ICIs) are the most notable breakthrough in tumor treatment. ICIs has been widely used in tumor patients, but its wide range of immune-related adverse events (irAEs) should not be ignored. irAEs can be involved in any organ system, including immune-related cardiotoxicity. Although the cardiotoxicity induced by immune checkpoint inhibitors is rare, it is extremely lethal and has attracted increasing attention. PD-1 and PD-L1 are expressed in human cardiomyocytes, so the application of PD-1/PDL-1 inhibitors can cause many adverse reactions to the cardiovascular system. This review summarizes the latest epidemiological evidence on the cardiovascular toxicity of programmed cell death protein-1(PD-1)/programmed cell death ligand-1(PD-L1) inhibitors and the clinical manifestations, as well as the potential pathological mechanisms. These updates may provide a novel perspective for monitoring early toxicity and establishing appropriate treatment for patients with ICI-related cardiotoxicity.

A Knowledge Graph Embedding Based Approach to Predict the Adverse Drug Reactions Using a Deep Neural Network

Recently Artificial Intelligence(AI) has not only been used to diagnose the disease but also to cure the disease. Researchers started using AI for drug discovery. Predicting the Adverse Drug Reactions(ADRs) caused by the drug in the manufacturing stage or in the clinical trial stage is a very important problem in drug discovery. ADRs have become a major concern resulting in injuries and also becoming fatal sometimes. Drug safety has gained much importance over the years propelling to the forefront investigation of predicting the ADRs. Although prior studies have queried diverse approaches to predict ADRs, very few were found to be effective. Also, the problem of having fewer reports makes the prediction of ADRs more difficult. To tackle this problem effectively, a novel method has been proposed in this paper. The proposed method is based on Knowledge Graph(KG) embedding. Using the KG embedding, we designed and trained a custom-made Deep Neural Network(DNN) called KGDNN(Knowledge Graph DNN) for predicting the ADRs. A KG has been constructed with 6 types of entities: drugs, ADRs, target proteins, indications, pathways, and genes. Using the Node2Vec algorithm, each node has been embedded into a feature space. Using those embeddings, the ADRs are classified by the KGDNN model. The proposed method has obtained an AUROC score of 0.917 and significantly outperformed the existing methods. Two case studies on drugs causing liver injury and COVID-19 recommended drugs have been performed to illustrate the model efficacy.

Immune Checkpoint Therapies and Atherosclerosis: Mechanisms and Clinical Implications: JACC State-of-the-Art Review

Immune checkpoint inhibitor therapy has revolutionized the treatment of advanced malignancies in recent years. Numerous reports have detailed the myriad of possible adverse inflammatory effects of immune checkpoint therapies, including within the cardiovascular system. However, these reports have been largely limited to myocarditis. The critical role of inflammation and adaptive immunity in atherosclerosis has been well characterized in preclinical studies, and several emerging clinical studies indicate a potential role of immune checkpoint targeting therapies in the development and exacerbation of atherosclerosis. In this review, we provide an overview of the role of T-cell immunity in atherogenesis and describe the molecular effects and clinical associations of both approved and investigational immune checkpoint therapy on atherosclerosis. We also highlight the role of cholesterol metabolism in oncogenesis and discuss the implications of these associations on future treatment and monitoring of atherosclerotic cardiovascular disease in the oncologic population receiving immune checkpoint therapy.

Steatosis, Steatohepatitis and Cancer Immunotherapy: An Intricate Story

Immune checkpoint inhibitors represent one of the most significant recent advances in clinical oncology, since they dramatically improved the prognosis of deadly cancers such as melanomas and lung cancer. Treatment with these drugs may be complicated by the occurrence of clinically-relevant adverse drug reactions, most of which are immune-mediated, such as pneumonitis, colitis, endocrinopathies, nephritis, Stevens Johnson syndrome and toxic epidermal necrolysis. Drug-induced steatosis and steatohepatitis are not included among the typical forms of cancer immunotherapy-induced liver toxicity, which, instead, usually occurs as a panlobular hepatitis with prominent lymphocytic infiltrates. Nonetheless, non-alcoholic fatty liver disease is a risk factor for immunotherapy-induced hepatitis, and steatosis and steatohepatitis are frequently observed in this condition. In the present review we discuss how these pathology findings could be explained in the context of current models suggesting immune-mediated pathogenesis for steatohepatitis. We also review evidence suggesting that in patients with hepatocellular carcinoma, the presence of steatosis or steatohepatitis could predict a poor therapeutic response to these agents. How these findings could fit with immune-mediated mechanisms of these liver diseases will also be discussed.

Immune checkpoint inhibitors and cardiotoxicity: possible mechanisms, manifestations, diagnosis and management

INTRODUCTION

Immune checkpoint inhibitors (ICIs) are a new class of anticancer drugs that enhance the immune system function and activate T cells against cancerous cells. Although cardiac complications are not common, they could be accompanied with high morbidity and mortality.

AREAS COVERED

Regarding the importance of cardiac complications and their subsequent burden on individuals and the healthcare system, this review attempts to discuss the mechanism, diagnosis, and management of myocarditis, besides recapitulating the possible mechanism of other cardiac adverse events. Moreover, we briefly discuss the concurrent administration of other chemotherapeutic agents.

EXPERT OPINION

Due to insufficient knowledge concerning the physiopathology of immune-related adverse events (irAEs) and their potential further complications, cardiovascular complications in particular and in the context of this paper's focus, cooperation of oncologists, immunologists, and cardiologists is necessary for the management of patients. Experimental approaches such as using corticosteroids are becoming a part of guidelines for managing cardiac irAEs. However, a unique algorithm for diagnosis and management is necessary, especially in myocarditis cases. Furthermore, more studies are required to resolve current challenges, including prevention of myocarditis, concurrent administration of other chemotherapeutic agents, and re-introducing patients with ICIs.

Cancer patients receiving immune checkpoint inhibitor therapy are at an increased risk for atherosclerotic cardiovascular disease

The widespread clinical use of immune checkpoint inhibitors (ICI) has increased our knowledge on their adverse effects on chronic inflammatory diseases. Atherosclerosis, a low-grade lipid-driven inflammatory disease of the larger arteries, is commonly present in cancer patients. A major concern is the adverse effect of ICI on atherosclerosis-related cardiovascular disease, resulting in cardiovascular events, such as myocardial infarction or ischaemic stroke. The effects of ICI on atherosclerosis in cancer patients are incompletely understood, but it is well known that immune checkpoint proteins orchestrate the inflammatory response underlying atherogenesis. This paper addresses the hypothesis that ICI therapy puts cancer patients at an increased risk for atherosclerosis-related cardiovascular disease, that might only become apparent years after ICI therapy. Until clinical and experimental studies have addressed this hypothesis, optimal cardiovascular risk management in ICI-treated patients is opportune to reduce the occurrence of cardiovascular disease in cancer patients and long-term cancer survivors.

Immune Checkpoint Inhibitors and Atherosclerotic Vascular Events in Cancer Patients

In clinical trials and meta-analysis, atherosclerotic vascular events (AVEs) during treatment with immune-checkpoint inhibitors (ICIs) have been reported with low incidence. However, preclinical data suggest that these drugs can promote atherosclerosis inflammation and progression of atherosclerosis plaques, and there is now growing and convincing evidence from retrospective studies that ICIs increase the risk of atherosclerotic vascular events including arterial thrombosis, myocardial infarction and ischemic stroke. Prospective studies are needed to increase knowledge on long-term effect of ICIs or their combinations with other cardio-toxic drugs, but in the meantime a careful assessment and optimization of cardiovascular risk factors among patients treated with ICIs is advisable.

Prediction of adverse drug reactions based on knowledge graph embedding

BACKGROUND

Adverse drug reactions (ADRs) are an important concern in the medication process and can pose a substantial economic burden for patients and hospitals. Because of the limitations of clinical trials, it is difficult to identify all possible ADRs of a drug before it is marketed. We developed a new model based on data mining technology to predict potential ADRs based on available drug data.

METHOD

Based on the Word2Vec model in Nature Language Processing, we propose a new knowledge graph embedding method that embeds drugs and ADRs into their respective vectors and builds a logistic regression classification model to predict whether a given drug will have ADRs.

RESULT

First, a new knowledge graph embedding method was proposed, and comparison with similar studies showed that our model not only had high prediction accuracy but also was simpler in model structure. In our experiments, the AUC of the classification model reached a maximum of 0.87, and the mean AUC was 0.863.

CONCLUSION

In this paper, we introduce a new method to embed knowledge graph to vectorize drugs and ADRs, then use a logistic regression classification model to predict whether there is a causal relationship between them. The experiment showed that the use of knowledge graph embedding can effectively encode drugs and ADRs. And the proposed ADRs prediction system is also very effective.

Immune Checkpoint Inhibitor Therapy Aggravates T Cell-Driven Plaque Inflammation in Atherosclerosis

BACKGROUND

Immunotherapy has revolutionized cancer treatment. However, immune checkpoint inhibitors (ICIs) that target PD-1 (programmed cell death protein-1) and/or CTLA-4 (cytotoxic T lymphocyte-associated antigen-4) are commonly associated with acute immune-related adverse events. Accumulating evidence also suggests that ICIs aggravate existing inflammatory diseases.

OBJECTIVES

As inflammation drives atherosclerotic cardiovascular disease, we studied the propensity of short-term ICI therapy to aggravate atherosclerosis.

METHODS

We used 18F-FDG (2-deoxy-2-[fluorine-18]fluoro-D-glucose) positron emission tomography-computed tomography to detect macrophage-driven vascular and systemic inflammation in pembrolizumab and nivolumab/ipilimumab-treated melanoma patients. In parallel, atherosclerotic Ldlr -/- mice were treated with CTLA-4 and PD-1 inhibition to study the proinflammatory consequences of immune checkpoint inhibition.

RESULTS

ICI treatment did not affect 18F-FDG uptake in the large arteries, spleen, and bone marrow of melanoma patients, nor myeloid cell activation in blood and lymphoid organs in hyperlipidemic mice. In contrast, we found marked changes in the adaptive immune response (i.e., increased CD4+ effector T cell and CD8+ cytotoxic T cell numbers in lymphoid organs and the arterial wall of our hyperlipidemic mice). Although plaque size was unaffected, plaques had progressed toward a lymphoid-based inflammatory phenotype, characterized by a 2.7-fold increase of CD8+ T cells and a 3.9-fold increase in necrotic core size. Increased endothelial activation was observed with a 2.2-fold and 1.6-fold increase in vascular cell adhesion molecule-1 and intercellular adhesion molecule-1, respectively.

CONCLUSIONS

This study demonstrates that combination therapy with anti-CTLA-4 and anti-PD-1 antibodies does not affect myeloid-driven vascular and systemic inflammation in melanoma patients and hyperlipidemic mice. However, short-term ICI therapy in mice induces T cell-mediated plaque inflammation and drives plaque progression.

Delicate Role of PD-L1/PD-1 Axis in Blood Vessel Inflammatory Diseases: Current Insight and Future Significance

Immune checkpoint molecules are the antigen-independent generator of secondary signals that aid in maintaining the homeostasis of the immune system. The programmed death ligand-1 (PD-L1)/PD-1 axis is one among the most extensively studied immune-inhibitory checkpoint molecules, which delivers a negative signal for T cell activation by binding to the PD-1 receptor. The general attributes of PD-L1's immune-suppressive qualities and novel mechanisms on the barrier functions of vascular endothelium to regulate blood vessel-related inflammatory diseases are concisely reviewed. Though targeting the PD-1/PD-L1 axis has received immense recognition-the Nobel Prize in clinical oncology was awarded in the year 2018 for this discovery-the use of therapeutic modulating strategies for the PD-L1/PD-1 pathway in chronic inflammatory blood vessel diseases is still limited to experimental models. However, studies using clinical specimens that support the role of PD-1 and PD-L1 in patients with underlying atherosclerosis are also detailed. Of note, delicate balances in the expression levels of PD-L1 that are needed to preserve T cell immunity and to curtail acute as well as chronic infections in underlying blood vessel diseases are discussed. A significant link exists between altered lipid and glucose metabolism in different cells and the expression of PD-1/PD-L1 molecules, and its possible implications on vascular inflammation are justified. This review summarizes the most recent insights concerning the role of the PD-L1/PD-1 axis in vascular inflammation and, in addition, provides an overview exploring the novel therapeutic approaches and challenges of manipulating these immune checkpoint proteins, PD-1 and PD-L1, for suppressing blood vessel inflammation.

New disappearance of complicated atheromatous plaques on rechallenge with PD-1/PD-L1 axis blockade in non-small cell lung cancer patient: follow up of an unexpected event

Atherosclerosis is considered an irreversible process, with crucial contribution of inflammation and immune cells. Impact of cancer immunotherapy on a partly immune-driven disease, such as atherosclerosis, is poorly understood, but preclinical models suggest its worsening on programmed death/ligand-1 (PD-1/PD-L1) inhibitors. In a previously reported cohort of 11 patients with non-small cell lung cancer (NSCLC) treated with nivolumab and pre-existing complicated atheromatous plaques, 3 patients had a dramatic radiologic reduction of aortic plaques while on nivolumab; of these 3, 2 died receiving no further treatment. The remaining patient was an 83-year-old woman with history of arterial hypertension and hypothyroidism who was diagnosed with locally advanced squamous NSCLC. At relapse, complicated aortic atheromatous plaques were demonstrated on scans. The patient was then treated with nivolumab obtaining stable disease at radiological assessment, which also demonstrated almost complete vanishing of aortic plaques. After relapse and interval treatment with chemotherapy, she experienced new development of aortic atheromatous plaques. At further relapse she received atezolizumab, which yielded disease response and new reduction in aortic plaques, until nearly complete resolution. The observation of a repeated improvement of atheromatous plaques on treatment with PD-1/PD-L1 inhibitors favors the protective role of T cells on atheromatous plaques that is impaired by PD-L1 expression by plaque-associated macrophages. Validation by independent and prospective observation is needed.