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Cartas-Espinel I, Telechea-Fernández M, Manterola Delgado C, Ávila Barrera A, Saavedra Cuevas N, Riffo-Campos AL. Novel molecular biomarkers of cancer therapy-induced cardiotoxicity in adult population: a scoping review. ESC Heart Fail 2022; 9:1651-1665. [PMID: 35261178 PMCID: PMC9065865 DOI: 10.1002/ehf2.13735] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 11/03/2021] [Accepted: 11/11/2021] [Indexed: 12/15/2022] Open
Abstract
Aim Cancer treatments are associated with cardiotoxic events that predispose to cardiac pathology and compromise the survival of patients, making necessary the identification of new molecular biomarkers to detect cardiotoxicity. This scoping review aims to identify the available evidence on novel molecular biomarkers associated with cardiotoxicity in the adult population undergoing cancer therapy. Methods and results The databases Medline, Web of Science, Scopus, and Embase were screened for the identification of published studies until 23 August 2020, searching for novel molecular biomarkers reported in cancer therapy‐related cardiac dysfunction in adult patients. A total of 42 studies that met the eligibility criteria were included. Fourteen studies reported 44 new protein biomarkers, 18 studies reported 57 new single nucleotide polymorphism biomarkers, and 11 studies reported 171 new gene expression profiles associated with cardiotoxicity. Data were extracted for 272 novel molecular biomarkers reported and evaluated in 7084 cancer patients, of which only 13 were identified in more than one study (MPO, sST2, GDF‐15, TGF‐B1, rs1056892, rs1883112, rs4673, rs13058338, rs1695, miR‐1, miR‐25‐3p, miR‐34a‐5p, and miR‐423‐5p), showing values for area under the curve > 0.73 (range 0.74–0.85), odds ratio 0.26–7.17, and hazard ratio 1.28–1.80. Conclusions Multiple studies presented a significant number of novel molecular biomarkers as promising predictors for risk assessment of cardiac dysfunction related to cancer therapy, but the characteristics of the studies carried out and the determinations applied do not allow suggesting the clinical use of these molecular biomarkers in the assessment of cancer therapy‐induced cardiotoxicity.
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Affiliation(s)
- Irene Cartas-Espinel
- Programa de Doctorado en Ciencias mención Biología Celular y Molecular Aplicada, Universidad de La Frontera, Temuco, Chile
| | | | - Carlos Manterola Delgado
- Departamento de Cirugía, Universidad de La Frontera, Temuco, Chile.,Centro de Excelencia en Estudios Morfológicos y Quirúrgicos (CEMyQ), Universidad de La Frontera, Temuco, Chile.,Programa de Doctorado en Ciencias Médicas, Universidad de La Frontera, Temuco, Chile
| | - Andrés Ávila Barrera
- Centro de Excelencia de Modelación y Computación Científica, Universidad de La Frontera, Temuco, Chile
| | | | - Angela L Riffo-Campos
- Programa de Doctorado en Ciencias Médicas, Universidad de La Frontera, Temuco, Chile.,Vicerrectoría Académica, Universidad de La Frontera, Temuco, Chile
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Cardiomyopathic Toxicity From Chemotherapy: Is There an Opportunity for Preemptive Intervention? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:20. [PMID: 28299613 DOI: 10.1007/s11936-017-0517-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OPINION STATEMENT The fight against cancer has never appeared more optimistic with multiple ongoing advances in cancer therapeutics; however, the prevention of cardiotoxicity from these treatments, both old and new, is a major focus of recent research. We recommend conceptualizing the prevention of cardiotoxicity as binary whereby primary prevention involves a uniform application of preventative efforts to anyone receiving a potentially cardiotoxic drug and secondary prevention directed towards those with left ventricular dysfunction, whether symptomatic or not. Recent studies suggest that cardioprotective medications such as renin-angiotensin inhibitors and beta blockers, among others, may be beneficial in the primary prevention of cardiotoxicity. Importantly, the magnitude of this protective effect appears to be driven by baseline risk of cardiac disease. In terms of secondary prevention, we recommend that patients with symptomatic heart failure related to cancer treatment should be treated as aggressively as patients with heart failure from other causes, as indicated by the most recent guidelines. We identify a relative paucity of data to guide those with asymptomatic left ventricular dysfunction. We summarize the literature to date with an emphasis on recent investigation and outline the importance of a continued partnership between cardiologists, oncologists, and primary care providers.
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Lenihan DJ, Anderson SA, Lenneman CG, Brittain E, Muldowney JA, Mendes L, Zhao PZ, Iaci J, Frohwein S, Zolty R, Eisen A, Sawyer DB, Caggiano AO. A Phase I, Single Ascending Dose Study of Cimaglermin Alfa (Neuregulin 1β3) in Patients With Systolic Dysfunction and Heart Failure. JACC Basic Transl Sci 2016; 1:576-586. [PMID: 30167542 PMCID: PMC6113538 DOI: 10.1016/j.jacbts.2016.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 09/27/2016] [Accepted: 09/28/2016] [Indexed: 01/03/2023]
Abstract
A first-in-human, phase 1, double blind, placebo-controlled, single ascending dose study examined the safety, tolerability, and exploratory efficacy of intravenous infusion of a recombinant growth factor, cimaglermin alfa, in patients with heart failure and left ventricular systolic dysfunction (LVSD). In these patients on optimal guideline-directed medical therapy, cimaglermin treatment was generally tolerated except for transient nausea and headache and a dose-limiting toxicity was noted at the highest planned dose. There was a dose-dependent improvement in left ventricular ejection fraction lasting 90 days following infusion. Thus, cimaglermin is a potential therapy to enhance cardiac function in LVSD and warrants further investigation.
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Key Words
- AE, adverse event
- AUC, area under the curve
- DLT, dose-limiting toxicity
- GGF, glial growth factor
- HF, heart failure
- LVEF, left ventricular ejection fraction
- LVSD, left ventricular systolic dysfunction
- NRG, neuregulin
- NYHA, New York Heart Association functional class
- TEAE, treatment-emergent adverse event
- cardiac repair
- growth factor
- neuregulin
- systolic dysfunction
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Affiliation(s)
- Daniel J. Lenihan
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee
| | - Sarah A. Anderson
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee
| | | | - Evan Brittain
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee
| | - James A.S. Muldowney
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee
| | - Lisa Mendes
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee
| | | | | | - Stephen Frohwein
- Emory Heart and Vascular Center at Emory Saint Joseph’s, Atlanta, Georgia
| | - Ronald Zolty
- University of Nebraska Medical Center, Omaha, Nebraska
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Harrison JM, Stella PJ, LaVasseur B, Adams PT, Swafford L, Lewis J, Mendelsohn-Victor K, Friese CR. Toxicity-Related Factors Associated With Use of Services Among Community Oncology Patients. J Oncol Pract 2016; 12:e818-27. [PMID: 27407166 DOI: 10.1200/jop.2016.010959] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Community oncology practices frequently manage chemotherapy-associated toxicities, which may disrupt treatment, impair quality of life, and induce unplanned service use. We sought to understand the patterns and correlates of unplanned health care service use among patients receiving first-cycle chemotherapy at five community-based ambulatory oncology practices. PATIENTS AND METHODS A survey study examined the dichotomous outcome of unplanned service use, defined as oncologist visits, emergency department visits, and hospitalizations, resulting from toxicity-related factors. Newly diagnosed patients with breast, lung, head and neck, or colorectal cancer or non-Hodgkin lymphoma were recruited during the first chemotherapy cycle. Before beginning the second cycle of chemotherapy, patients completed a questionnaire that measured unplanned service use and overall distress, plus severity of nausea, vomiting, diarrhea, constipation, mouth sores, intravenous catheter problems, pain, fever and chills, extremity edema, and dyspnea on a 5-point scale (1, did not experience; 5, disabling). Medical record reviews captured chemotherapy doses, comorbid conditions, and supportive care interventions. Mixed-effects logistic regression was used to identify factors associated with unplanned service use, with random effects specified for each clinic. RESULTS Among 106 patients (white, 98%; female, 74.5%; mean age ± standard deviation, 60 ± 11 years), frequently reported toxicities were pain, nausea, diarrhea, and constipation. Thirty-six patients (34%) reported unplanned service use: 29% reported oncologist visits, 14% reported emergency department visits, and 8% reported hospitalizations. Factors significantly associated with unplanned service use were high patient-reported distress and receipt of colony-stimulating factor. CONCLUSION Service use resulting from toxicity-related factors occurs frequently in community oncology settings. Monitoring toxicity patterns and outcomes can inform proactive symptom management approaches to reduce toxicity burden between scheduled visits.
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Affiliation(s)
- Jordan M Harrison
- University of Michigan; St Joseph Mercy Hospital Cancer Center, Ann Arbor; and Genesys Hurley Cancer Institute, Flint, MI
| | - Philip J Stella
- University of Michigan; St Joseph Mercy Hospital Cancer Center, Ann Arbor; and Genesys Hurley Cancer Institute, Flint, MI
| | - Beth LaVasseur
- University of Michigan; St Joseph Mercy Hospital Cancer Center, Ann Arbor; and Genesys Hurley Cancer Institute, Flint, MI
| | - Paul T Adams
- University of Michigan; St Joseph Mercy Hospital Cancer Center, Ann Arbor; and Genesys Hurley Cancer Institute, Flint, MI
| | - Lauren Swafford
- University of Michigan; St Joseph Mercy Hospital Cancer Center, Ann Arbor; and Genesys Hurley Cancer Institute, Flint, MI
| | - JoAnn Lewis
- University of Michigan; St Joseph Mercy Hospital Cancer Center, Ann Arbor; and Genesys Hurley Cancer Institute, Flint, MI
| | - Kari Mendelsohn-Victor
- University of Michigan; St Joseph Mercy Hospital Cancer Center, Ann Arbor; and Genesys Hurley Cancer Institute, Flint, MI
| | - Christopher R Friese
- University of Michigan; St Joseph Mercy Hospital Cancer Center, Ann Arbor; and Genesys Hurley Cancer Institute, Flint, MI
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The Utility of Point-of-Care Biomarkers to Detect Cardiotoxicity During Anthracycline Chemotherapy: A Feasibility Study. J Card Fail 2016; 22:433-8. [DOI: 10.1016/j.cardfail.2016.04.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 04/01/2016] [Accepted: 04/07/2016] [Indexed: 02/07/2023]
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Maurea N, Spallarossa P, Cadeddu C, Madonna R, Mele D, Monte I, Novo G, Pagliaro P, Pepe A, Tocchetti CG, Zito C, Mercuro G. A recommended practical approach to the management of target therapy and angiogenesis inhibitors cardiotoxicity: an opinion paper of the working group on drug cardiotoxicity and cardioprotection, Italian Society of Cardiology. J Cardiovasc Med (Hagerstown) 2016; 17 Suppl 1:S93-S104. [PMID: 27183530 PMCID: PMC4927319 DOI: 10.2459/jcm.0000000000000383] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Indexed: 12/21/2022]
Abstract
The US National Cancer Institute estimates that cardiotoxicity (CTX) from target therapy refers mostly to four groups of drugs: epidermal growth factor receptor 2 inhibitors, angiogenic inhibitors, directed Abelson murine leukemia viral oncogene homolog inhibitors, and proteasome inhibitors. The main cardiotoxic side-effects related to antiepidermal growth factor receptor 2 therapy are left ventricular systolic dysfunction and heart failure. Angiogenesis inhibitors are associated with hypertension, left ventricular dysfunction/heart failure, myocardial ischemia, QT prolongation, and thrombosis. Moreover, other agents may be related to CTX induced by treatment. In this study, we review the guidelines for a practical approach for the management of CTX in patients under anticancer target therapy.
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Affiliation(s)
- Nicola Maurea
- Division of Cardiology, Istituto Nazionale per lo Studio e la Cura dei Tumori ‘Fondazione Giovanni Pascale’ – IRCCS, Naples
| | | | - Christian Cadeddu
- Department of Medical Sciences ‘Mario Aresu’, University of Cagliari, Cagliari
| | - Rosalinda Madonna
- Institute of Cardiology, Center of Excellence on Aging, ‘G. d’Annunzio’ University, Chieti
| | - Donato Mele
- Cardiology Unit, University Hospital of Ferrara, Ferrara
| | - Ines Monte
- Department of General Surgery and Medical-Surgery Specialties, University of Catania, Catania
| | - Giuseppina Novo
- Chair and Division of Cardiology, University of Palermo, Palermo
| | - Pasquale Pagliaro
- Department of Clinical and Biological Sciences, University of Turin, Turin
| | - Alessia Pepe
- U.O.C. Magnetic Resonance Imaging, Fondazione G. Monasterio C.N.R., Pisa
| | - Carlo G. Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples
| | - Concetta Zito
- U.O.C. Cardiology Intensive Unit, A.O.U. Policlinico ‘G. Martino’, University of Messina, Messina, Italy
| | - Giuseppe Mercuro
- Department of Medical Sciences ‘Mario Aresu’, University of Cagliari, Cagliari
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Abstract
An ever-increasing array of chemotherapeutic agents is being used in the treatment of solid organ or hematologic malignancies. The success of many of these agents has led to an increasing survival of patients with cancer. However, many of these agents, particularly anthracyclines and trastuzumab, are associated with the development of cardiotoxicity. The current standard for the evaluation of chemotherapy-associated cardiotoxicity typically involves the use of serial measurements of left ventricular (LV) function by echocardiogram (Echo) and radionuclide ventriculogram (MUGA). Unfortunately, this time-honored method offers low sensitivity to the early prediction or detection of cardiac events. Frequently, by the time cardiotoxicity is detected, significant LV dysfunction has occurred and ultimately this may not respond to standard cardioprotective treatment. Cardiac biomarkers, troponin I and B-type natriuretic peptide, may allow a more accurate and timely monitoring strategy. The current data and a summarized understanding of how to utilize cardiac biomarkers for the prevention and early detection of cardiac dysfunction during chemotherapy are presented.
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Affiliation(s)
- Patrick L Stevens
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA,
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Cancer and Cardiovascular Disease: The Complex Labyrinth. JOURNAL OF ONCOLOGY 2015; 2015:516450. [PMID: 26345724 PMCID: PMC4539494 DOI: 10.1155/2015/516450] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/05/2015] [Indexed: 11/18/2022]
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Alıcı H, Balakan O, Ercan S, Çakıcı M, Yavuz F, Davutoğlu V. Evaluation of early subclinical cardiotoxicity of chemotherapy in breast cancer. Anatol J Cardiol 2014; 15:56-60. [PMID: 25179886 PMCID: PMC5336899 DOI: 10.5152/akd.2014.5185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: Cardiac effects of chemotherapy are usually recognized after clinical symptom or sign occurrence in patients with breast cancer. In this study, we aimed to determine the potential subclinical cardiotoxic effects of chemotherapy that were given lower dosage than well known cardiac safety dosage limits in patients with breast cancer during early period. Methods: Fifty-one patients consecutively enrolled to this prospective cohort study. All patients were diagnosed as breast cancer at oncology hospital in University of Gaziantep. Before chemotherapy, all of the patients underwent to detailed ECG and echocardiography (ECHO) examinations. After 6 months, detailed ECG and ECHO examinations were repeated and compared with baseline values. Statistical analysis was performed using Shapiro-Wilk tests, Student t-test and Spearman correlation test. Results: The average age of patients was 51 and one was male. Statistically significant decrease in ejection fraction was found after treatment (62.3%±3.3 and 59.9%±5.9, p=0.002). Evaluation of diastolic parameters; significant increase in the transmitral A flow velocity and significant decrease of E/A ratio were observed on Doppler ECHO analysis (77.4±19.1 cm/sec versus 86±18 cm/sec, p<0.001; 1.01±0.3 versus 0.9±0.2, p=0.03, respectively). On tissue Doppler analysis we observed that significant reduction in the value of E’ and significantly increase E/E’ ratio were present (12.5±3.6 cm/sec versus 10.7±2.9 cm/sec, p=0.001; 6.6±2.9 versus 7.7±3.3, p=0.04, respectively). Conclusion: Chemotherapy has detrimental subclinical effect on both of systolic and diastolic function in early six months period despite the prescription of lower dosage of chemotherapy than well-known cardiac safety dosage limits. Tissue Doppler imaging may be more sensitive than ECG, conventional ECHO and Doppler for determining the subclinical cardiac damage.
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Affiliation(s)
- Hayri Alıcı
- Clinic of Cardiology, 25 Aralık State Hospital, Gaziantep-Turkey.
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Balancing cancer treatment efficacy with the risk of cardiotoxicity and strategies for cardioprotection in adults. PROGRESS IN PEDIATRIC CARDIOLOGY 2014. [DOI: 10.1016/j.ppedcard.2014.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Cardiac Biomarkers, Cardiotoxicity, and Active Collaboration. J Am Coll Cardiol 2014; 63:817-8. [DOI: 10.1016/j.jacc.2013.10.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 10/01/2013] [Indexed: 11/30/2022]
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Lenihan DJ, Kowey PR. Overview and management of cardiac adverse events associated with tyrosine kinase inhibitors. Oncologist 2013; 18:900-8. [PMID: 23918069 PMCID: PMC3755926 DOI: 10.1634/theoncologist.2012-0466] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 06/17/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Small-molecule tyrosine kinase inhibitors (TKIs) may provide an effective therapeutic option in patients with hematologic malignancies and solid tumors. However, cardiovascular (CV) events, including hypertension, heart failure, left ventricular systolic dysfunction, and QT prolongation, have emerged as potential adverse events (AEs) with TKI therapy. PURPOSE We review what is known about the mechanism of action of CV AEs associated with TKI use and discuss therapeutic interventions that may prevent and manage these events in clinical practice. METHODS References for this review were identified through searches of PubMed and Medline databases, and only papers published in English were considered. Search terms included "cardiac," "cardiovascular," "cancer," and "kinase inhibitor." Related links in the databases were reviewed, along with relevant published guidelines. RESULTS Although the link between rising blood pressure (BP) and CV AEs is observed but not proven, good clinical practice supports an aggressive policy on proper long-term BP management. There are insufficient data from randomized controlled clinical trials to show indisputably that aggressive or effective heart failure therapy in patients receiving TKIs will fundamentally change outcomes; however, clinical practice suggests that this is an effective long-term approach. Recognizing that QT prolongation is associated with TKI use facilitates identification of patients at high risk for this CV AE and increases awareness of the need for routine electrocardiograms and electrolyte monitoring for those receiving TKI treatment. CONCLUSION Regular monitoring, early recognition, and appropriate interventions for CV AEs can help more patients derive the benefit of long-term TKI therapy.
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Affiliation(s)
- Daniel J Lenihan
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee 37232-8802, USA.
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Current World Literature. Curr Opin Cardiol 2013; 28:369-79. [DOI: 10.1097/hco.0b013e328360f5be] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Brown TR, Vijarnsorn C, Potts J, Milner R, Sandor GGS, Fryer C. Anthracycline induced cardiac toxicity in pediatric Ewing sarcoma: a longitudinal study. Pediatr Blood Cancer 2013; 60:842-8. [PMID: 23382019 DOI: 10.1002/pbc.24404] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 10/23/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Reports on incidence and factors associated with anthracycline cardiotoxicity in patients with Ewing sarcoma vary and few studies evaluate effect over time. Longitudinal trends in cardiac function and prognostic value of % decline in ejection fraction (EF) during therapy have not been previously described in Ewing sarcoma. PROCEDURE A retrospective review of patients age <17 years, diagnosed with Ewing sarcoma during 1978-2006, treated at British Columbia Children's Hospital with anthracycline chemotherapy was undertaken. Echocardiograms performed pre-treatment, worst function during treatment, on therapy completion; worst function during surveillance and the most recent echocardiogram were reviewed. Cardiac toxicity was graded using Common Terminology Criteria for Adverse Events v 3.0 and 4.0. RESULTS Among 71 eligible patients, median age at diagnosis 11.1 years, median cumulative dose of anthracycline was 365 mg/m2 . There were 397 echocardiograms with 153 (39%) abnormal. There were 21/71 patients with EF < 50%, 11 with EF < 40% and five cardiac deaths including 2/3 patients post-cardiac transplant. The median time to worst cardiac function was 51 months. Post-therapy completion 16/71 patients with progressive decline in cardiac function were noted. No patient with 10-15% decline in EF during therapy developed cardiotoxicity. Younger age (P = 0.004) and low BMI (P = 0.034) as continuous variables with anthracycline administration by IV push (P = 0.03) were risk factors for cardiotoxicity on univariate analysis but not significant within logistic regression models. CONCLUSIONS The high incidence of cardiotoxicity associated with higher administered anthracycline dose, young age, bolus infusion, and EF decline warrants evaluation in a larger cohort.
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Affiliation(s)
- Tanya Renae Brown
- Division of Pediatric Hematology, Oncology & Bone Marrow Transplantation, The British Columbia Children's Hospital, Vancouver, British Columbia, Canada.
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