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Xia ZG, Lv FF, Zhang QL, Liu YZ, Zhang SJ, Liu C, Li XQ, Wen Y, Wu ZY, Hong XN, Guo Y, Cao JN. Phase 2 study of pegylated liposomal doxorubicin plus cyclophosphamide, vincristine/vindesine, and prednisone in newly diagnosed PTCL: 8-year results. Oncologist 2024:oyae108. [PMID: 38821519 DOI: 10.1093/oncolo/oyae108] [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: 01/04/2024] [Accepted: 04/19/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Pegylated liposomal doxorubicin (PLD) is a liposome-encapsulated form of doxorubicin with equivalent efficacy and less cardiotoxicity. This phase 2 study evaluated the efficacy and safety of the PLD-containing CHOP regimen in newly diagnosed patients with aggressive peripheral T-cell lymphomas (PTCL). METHODS Patients received PLD, cyclophosphamide, vincristine/vindesine, plus prednisone every 3 weeks for up to 6 cycles. The primary endpoint was the objective response rate at the end of treatment (EOT). RESULTS From September 2015 to January 2017, 40 patients were treated. At the EOT, objective response was achieved by 82.5% of patients, with 62.5% complete response. As of the cutoff date (September 26, 2023), median progression-free survival (mPFS) and overall survival (mOS) were not reached (NR). The 2-year, 5-year, and 8-year PFS rates were 55.1%, 52.0%, and 52.0%. OS rate was 80.0% at 2 years, 62.5% at 5 years, and 54.3% at 8 years. Patients with progression of disease within 24 months (POD24) had worse prognosis than those without POD24, regarding mOS (41.2 months vs NR), 5-year OS (33.3% vs 94.4%), and 8-year OS (13.3% vs 94.4%). Common grade 3-4 adverse events were neutropenia (87.5%), leukopenia (80.0%), anemia (17.5%), and pneumonitis (17.5%). CONCLUSION This combination had long-term benefits and manageable tolerability, particularly with less cardiotoxicity, for aggressive PTCL, which might provide a favorable benefit-risk balance. CLINICALTRIALS.GOV IDENTIFIER Chinese Clinical Trial Registry, ChiCTR2100054588; IRB Approved: Ethics committee of Fudan University Shanghai Cancer Center (Date 2015.8.31/No. 1508151-13.
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Affiliation(s)
- Zu-Guang Xia
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Fang-Fang Lv
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Qun-Ling Zhang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Yi-Zhen Liu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Sheng-Jian Zhang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Chang Liu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
- Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Xiao-Qiu Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Yu Wen
- Department of Biostatistics, School of Public Health, Key Laboratory of Public Health Safety and Collaborative Innovation Center of Social Risks Governance in Health, Fudan University, Shanghai, People's Republic of China
| | - Zhen-Yu Wu
- Department of Biostatistics, School of Public Health, Key Laboratory of Public Health Safety and Collaborative Innovation Center of Social Risks Governance in Health, Fudan University, Shanghai, People's Republic of China
| | - Xiao-Nan Hong
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Ye Guo
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Jun-Ning Cao
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
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Díaz-Guerra A, Villena-Gutiérrez R, Clemente-Moragón A, Gómez M, Oliver E, Fernández-Tocino M, Galán-Arriola C, Cádiz L, Ibáñez B. Anthracycline Cardiotoxicity Induces Progressive Changes in Myocardial Metabolism and Mitochondrial Quality Control: Novel Therapeutic Target. JACC CardioOncol 2024; 6:217-232. [PMID: 38774018 PMCID: PMC11103041 DOI: 10.1016/j.jaccao.2024.02.005] [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] [Received: 09/11/2023] [Revised: 01/31/2024] [Accepted: 02/06/2024] [Indexed: 05/24/2024] Open
Abstract
Background Anthracycline-induced cardiotoxicity (AIC) debilitates quality of life in cancer survivors. Serial characterizations are lacking of the molecular processes occurring with AIC. Objectives The aim of this study was to characterize AIC progression in a mouse model from early (subclinical) to advanced heart failure stages, with an emphasis on cardiac metabolism and mitochondrial structure and function. Methods CD1 mice received 5 weekly intraperitoneal doxorubicin injections (5 mg/kg) and were followed by serial echocardiography for 15 weeks. At 1, 9, and 15 weeks after the doxorubicin injections, mice underwent fluorodeoxyglucose positron emission tomography, and hearts were extracted for microscopy and molecular analysis. Results Cardiac atrophy was evident at 1 week post-doxorubicin (left ventricular [LV] mass 117 ± 26 mg vs 97 ± 25 mg at baseline and 1 week, respectively; P < 0.001). Cardiac mass nadir was observed at week 3 post-doxorubicin (79 ± 16 mg; P = 0.002 vs baseline), remaining unchanged thereafter. Histology confirmed significantly reduced cardiomyocyte area (167 ± 19 μm2 in doxorubicin-treated mice vs 211 ± 26 μm2 in controls; P = 0.004). LV ejection fraction declined from week 6 post-doxorubicin (49% ± 9% vs 61% ± 9% at baseline; P < 0.001) until the end of follow-up at 15 weeks (43% ± 8%; P < 0.001 vs baseline). At 1 week post-doxorubicin, when LV ejection fraction remained normal, reduced cardiac metabolism was evident from down-regulated markers of fatty acid oxidation and glycolysis. Metabolic impairment continued to the end of follow-up in parallel with reduced mitochondrial adenosine triphosphate production. A transient early up-regulation of nutrient-sensing and mitophagy markers were observed, which was associated with mitochondrial enlargement. Later stages, when mitophagy was exhausted, were characterized by overt mitochondrial fragmentation. Conclusions Cardiac atrophy, global hypometabolism, early transient-enhanced mitophagy, biogenesis, and nutrient sensing constitute candidate targets for AIC prevention.
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Affiliation(s)
- Anabel Díaz-Guerra
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | | | - Agustín Clemente-Moragón
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Mónica Gómez
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Centro Nacional de Investigaciones Oncológicas, Madrid, Spain
| | - Eduardo Oliver
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
- Centro de Investigaciones Biológicas Margarita Salas, Madrid, Spain
| | - Miguel Fernández-Tocino
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Carlos Galán-Arriola
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Laura Cádiz
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - Borja Ibáñez
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
- Cardiology Department, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain
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Ositelu K, Trevino A, Tong A, Chen MH, Akhter N. Challenges in Cardiovascular Imaging in Women with Breast Cancer. Curr Cardiol Rep 2023; 25:1247-1255. [PMID: 37642930 DOI: 10.1007/s11886-023-01941-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 08/31/2023]
Abstract
Cardiovascular imaging in breast cancer patients is paramount for the surveillance of cancer therapy-related cardiac dysfunction (CTRCD); however, it comes with specific limitations. PURPOSE OF REVIEW: This review aims to describe the unique challenges faced in cardiovascular imaging of breast cancer patients, discuss evidence to support the utility of various imaging modalities, and provide solutions for improvement in imaging this unique population. RECENT FINDINGS: Updated clinical society guidelines have introduced more unifying surveillance of CTRCD, although there remains a lack of a universally accepted definition. Traditional and novel multi-modality imaging can be used to detect CTRCD and myocarditis in breast cancer patients. Cardiovascular imaging in breast cancer patients is difficult due to reconstructive surgery. Although echocardiography with myocardial strain is the cornerstone, multi-modality imaging can be used to evaluate for CTRCD and myocarditis. Novel imaging techniques to improve the diagnosis of cardiotoxicities in breast cancer patients are needed.
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Affiliation(s)
- Kamari Ositelu
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 600, Chicago, IL, USA
| | - Alexandra Trevino
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ann Tong
- The Cardiac & Vascular Institute, Gainesville, FL, USA
| | - Ming Hui Chen
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nausheen Akhter
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 600, Chicago, IL, USA.
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Oikawa M, Ishida T, Takeishi Y. Cancer therapeutics-related cardiovascular dysfunction: Basic mechanisms and clinical manifestation. J Cardiol 2023; 81:253-259. [PMID: 35589463 DOI: 10.1016/j.jjcc.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/01/2023]
Abstract
Although recent advances in cancer treatment improve cancer prognosis, cancer therapeutics-related cardiovascular dysfunction (CTRCD) significantly contributes to the global burden of cardiovascular disease. CTRCD causes two crucial issues: first, premature treatment interruption or discontinuation of chemotherapy; second, the development of congestive heart failure during and after cancer treatment. Thus, early detection and prompt treatment of CTRCD may improve the prognosis in cancer patients. This review covers representative anticancer drugs, including anthracyclines, human epidermal growth factor 2 inhibitors, tyrosine kinase inhibitors, proteasome inhibitors, and immune checkpoint inhibitors. We focus on the molecular mechanisms of CTRCD and various approaches to diagnosis, prevention, monitoring, and treatment.
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Affiliation(s)
- Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University, 1-Hikarigaoka, Fukushima, Fukushima prefecture 960-1295, Japan.
| | - Takafumi Ishida
- Department of Cardiovascular Medicine, Fukushima Medical University, 1-Hikarigaoka, Fukushima, Fukushima prefecture 960-1295, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, 1-Hikarigaoka, Fukushima, Fukushima prefecture 960-1295, Japan
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5
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Seara FAC, Maciel L, Kasai-Brunswick TH, Nascimento JHM, Campos-de-Carvalho AC. Extracellular Vesicles and Cardiac Aging. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1418:33-56. [PMID: 37603271 DOI: 10.1007/978-981-99-1443-2_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Global population aging is a major challenge to health and socioeconomic policies. The prevalence of diseases progressively increases with aging, with cardiovascular disease being the major cause of mortality among elderly people. The allostatic overload imposed by the accumulation of cardiac senescent cells has been suggested to play a pivotal role in the aging-related deterioration of cardiovascular function. Senescent cells exhibit intrinsic disorders and release a senescence-associated secretory phenotype (SASP). Most of these SASP compounds and damaged molecules are released from senescent cells by extracellular vesicles (EVs). Once secreted, these EVs can be readily incorporated by recipient neighboring cells and elicit cellular damage or otherwise can promote extracellular matrix remodeling. This has been associated with the development of cardiac dysfunction, fibrosis, and vascular calcification, among others. The molecular signature of these EVs is highly variable and might provide important information for the development of aging-related biomarkers. Conversely, EVs released by the stem and progenitor cells can exert a rejuvenating effect, raising the possibility of future anti-aging therapies.
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Affiliation(s)
- Fernando A C Seara
- Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Physiological Sciences, Institute of Health and Biological Sciences, Federal Rural University of Rio de Janeiro, Seropédica, Brazil
| | - Leonardo Maciel
- Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Federal University of Rio de Janeiro, Campus Professor Geraldo, Duque de Caxias, Brazil
| | - Tais Hanae Kasai-Brunswick
- Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- National Center of Structural Biology and Bioimaging, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jose H M Nascimento
- Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
- Laboratory of Cardiac Electrophysiology, Carlos Chagas Filho Institute of Biophysics, Health Sciences Centre, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
| | - Antonio C Campos-de-Carvalho
- Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- National Center of Structural Biology and Bioimaging, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Prathumsap N, Ongnok B, Khuanjing T, Arinno A, Maneechote C, Apaijai N, Chunchai T, Arunsak B, Kerdphoo S, Janjek S, Chattipakorn SC, Chattipakorn N. Vagus nerve stimulation exerts cardioprotection against doxorubicin-induced cardiotoxicity through inhibition of programmed cell death pathways. Cell Mol Life Sci 2022; 80:21. [PMID: 36583785 PMCID: PMC11072695 DOI: 10.1007/s00018-022-04678-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 12/07/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
The aberration of programmed cell death including cell death associated with autophagy/mitophagy, apoptosis, necroptosis, pyroptosis, and ferroptosis can be observed in the development and progression of doxorubicin-induced cardiotoxicity (DIC). Vagus nerve stimulation (VNS) has been shown to exert cardioprotection against cardiomyocyte death through the release of the neurotransmitter acetylcholine (ACh) under a variety of pathological conditions. However, the roles of VNS and its underlying mechanisms against DIC have never been investigated. Forty adults male Wistar rats were divided into 5 experimental groups: (i) control without VNS (CSham) group, (ii) doxorubicin (3 mg/kg/day, i.p.) without VNS (DSham) group, (iii) doxorubicin + VNS (DVNS) group, (iv) doxorubicin + VNS + mAChR antagonist (atropine; 1 mg/kg/day, ip, DVNS + Atro) group, and (v) doxorubicin + VNS + nAChR antagonist (mecamylamine; 7.5 mg/kg/day, ip, DVNS + Mec) group. Our results showed that doxorubicin insult led to left ventricular (LV) dysfunction through impaired cardiac autonomic balance, decreased mitochondrial function, imbalanced mitochondrial dynamics, and exacerbated cardiomyocyte death including autophagy/mitophagy, apoptosis, necroptosis, pyroptosis, and ferroptosis. However, VNS treatment improved cardiac mitochondrial and autonomic functions, and suppressed excessive autophagy, apoptosis, necroptosis, pyroptosis, and ferroptosis, leading to improved LV function. Consistent with this, ACh effectively improved cell viability and suppressed cell cytotoxicity in doxorubicin-treated H9c2 cells. In contrast, either inhibitors of muscarinic (mAChR) or nicotinic acetylcholine receptor (nAChR) completely abrogated the favorable effects mediated by VNS and acetylcholine. These findings suggest that VNS exerts cardioprotective effects against doxorubicin-induced cardiomyocyte death via activation of both mAChR and nAChR.
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Affiliation(s)
- Nanthip Prathumsap
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Benjamin Ongnok
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Thawatchai Khuanjing
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Apiwan Arinno
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Chayodom Maneechote
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Nattayaporn Apaijai
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Titikorn Chunchai
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Busarin Arunsak
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Sasiwan Kerdphoo
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Sornram Janjek
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand
- Department of Oral Biology and Diagnostic Science, Faculty of Dentistry, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
- Center of Excellence in Cardiac Electrophysiology, Chiang Mai University, Chiang Mai, 50200, Thailand.
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Jong J, Pinney JR, Packard RRS. Anthracycline-induced cardiotoxicity: From pathobiology to identification of molecular targets for nuclear imaging. Front Cardiovasc Med 2022; 9:919719. [PMID: 35990941 PMCID: PMC9381993 DOI: 10.3389/fcvm.2022.919719] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/28/2022] [Indexed: 11/19/2022] Open
Abstract
Anthracyclines are a widely used class of chemotherapy in pediatric and adult cancers, however, their use is hampered by the development of cardiotoxic side-effects and ensuing complications, primarily heart failure. Clinically used imaging modalities to screen for cardiotoxicity are mostly echocardiography and occasionally cardiac magnetic resonance imaging. However, the assessment of diastolic and global or segmental systolic function may not be sensitive to detect subclinical or early stages of cardiotoxicity. Multiple studies have scrutinized molecular nuclear imaging strategies to improve the detection of anthracycline-induced cardiotoxicity. Anthracyclines can activate all forms of cell death in cardiomyocytes. Injury mechanisms associated with anthracycline usage include apoptosis, necrosis, autophagy, ferroptosis, pyroptosis, reactive oxygen species, mitochondrial dysfunction, as well as cardiac fibrosis and perturbation in sympathetic drive and myocardial blood flow; some of which have been targeted using nuclear probes. This review retraces the pathobiology of anthracycline-induced cardiac injury, details the evidence to date supporting a molecular nuclear imaging strategy, explores disease mechanisms which have not yet been targeted, and proposes a clinical strategy incorporating molecular imaging to improve patient management.
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Affiliation(s)
- Jeremy Jong
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - James R. Pinney
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
- Veterans Affairs West Los Angeles Medical Center, Los Angeles, CA, United States
| | - René R. Sevag Packard
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
- Veterans Affairs West Los Angeles Medical Center, Los Angeles, CA, United States
- Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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8
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Herrmann J, McCullough KB, Habermann TM. How I treat cardiovascular complications in patients with lymphoid malignancies. Blood 2022; 139:1501-1516. [PMID: 34752600 PMCID: PMC8914183 DOI: 10.1182/blood.2019003893] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
The prognosis of several lymphoid malignancies has improved through development of novel therapies, combination with traditional chemotherapies, and delineation of appropriate therapeutic sequencing. Toxicities that are arising because of prolonged or multiple sequential therapeutic interventions are becoming increasingly impactful. Among the broad spectrum of complications that patients with lymphoid malignancies may experience, cardiovascular toxicities are significant in terms of morbidity and mortality. The entire cardiovascular system can be affected, but cardiomyopathy, heart failure, and arrhythmias remain of greatest concerns with the use of anthracyclines, hematopoietic stem cell transplantation, and radiation therapy in patients with lymphoid malignancies. These aspects will be covered in this article within the framework of case-based discussions. Key to the management of cardiovascular complications in patients with lymphoid malignancies is awareness and preparedness across the cancer continuum. Baseline risk stratification helps to direct surveillance and early intervention efforts before, during, and after cancer therapy, which are paramount for the best possible outcomes. Along these lines, the overall goal is to enable the best possible therapies for lymphoid malignancies without the complications of clinically significant cardiovascular events.
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Affiliation(s)
| | | | - Thomas M Habermann
- 3Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Liu K, Zhang J, Li X, Xie Y, Li Y, Wang X, Jiao X, Xie X, Tang B. Hypochlorous acid-activated two-photon fluorescent probe for evaluation of anticancer drug-induced cardiotoxicity and screening of antioxidant drugs. Org Chem Front 2022. [DOI: 10.1039/d2qo01408d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
THPIC was developed to detect HClO in lysosomes. The results showed that HClO could be used as a biomarker for evaluating drug-induced cardiotoxicity, and THPIC could be applied as a platform for screening drugs to prevent cardiotoxicitys.
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Affiliation(s)
- Kaiqiang Liu
- College of Chemistry, Chemical Engineering and Materials Science, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Shandong Provincial Key Laboratory of Clean Production of Fine Chemicals, Shandong Normal University, Jinan 250014, P. R. China
| | - Jian Zhang
- College of Chemistry, Chemical Engineering and Materials Science, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Shandong Provincial Key Laboratory of Clean Production of Fine Chemicals, Shandong Normal University, Jinan 250014, P. R. China
| | - Xinxin Li
- College of Chemistry, Chemical Engineering and Materials Science, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Shandong Provincial Key Laboratory of Clean Production of Fine Chemicals, Shandong Normal University, Jinan 250014, P. R. China
| | - Yingying Xie
- College of Chemistry, Chemical Engineering and Materials Science, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Shandong Provincial Key Laboratory of Clean Production of Fine Chemicals, Shandong Normal University, Jinan 250014, P. R. China
| | - Yong Li
- College of Chemistry, Chemical Engineering and Materials Science, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Shandong Provincial Key Laboratory of Clean Production of Fine Chemicals, Shandong Normal University, Jinan 250014, P. R. China
| | - Xu Wang
- College of Chemistry, Chemical Engineering and Materials Science, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Shandong Provincial Key Laboratory of Clean Production of Fine Chemicals, Shandong Normal University, Jinan 250014, P. R. China
| | - Xiaoyun Jiao
- College of Chemistry, Chemical Engineering and Materials Science, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Shandong Provincial Key Laboratory of Clean Production of Fine Chemicals, Shandong Normal University, Jinan 250014, P. R. China
| | - Xilei Xie
- College of Chemistry, Chemical Engineering and Materials Science, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Shandong Provincial Key Laboratory of Clean Production of Fine Chemicals, Shandong Normal University, Jinan 250014, P. R. China
| | - Bo Tang
- College of Chemistry, Chemical Engineering and Materials Science, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Shandong Provincial Key Laboratory of Clean Production of Fine Chemicals, Shandong Normal University, Jinan 250014, P. R. China
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10
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Aslam S, Ameer S, Shabana NA, Ahmed M. Pharmacogenetics of induction therapy-related toxicities in childhood acute lymphoblastic leukemia patients treated with UKALL 2003 protocol. Sci Rep 2021; 11:23757. [PMID: 34887513 PMCID: PMC8660848 DOI: 10.1038/s41598-021-03208-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/30/2021] [Indexed: 11/17/2022] Open
Abstract
Chemotherapy related toxicities have been the major factor limiting the success of acute lymphoblastic leukemia (ALL) induction therapy. Several factors, including the pharmacogenetics of asparaginase and anthracyclines, could contribute to difference in treatment outcome in ALL. We investigated the significance of variations in genes involved in hepatic and cardiac toxicity in acute lymphoblastic leukemia (ALL). Genotyping of SOD2 (rs4880), PNPL3 (rs738409) and ABCC1 (rs4148350), CBR1 (rs9024) and ABCG2 (rs2231142) was performed by Tetra-ARMS PCR-based technique to evaluate the genotype-phenotype correlation. Our results showed only minor allele G of SOD2 rs4880 increase the risk of hepatic toxicity [OR 2.63 (1.42-4.84), P = < 0.05] while minor alleles of other SNPs showed protective impact. However, the genetic contrast analysis showed a recessive form of SOD2 rs4880 [OR 7.82 (3.86-15.85), P = < 0.05] and PNPLA3 I148M [OR 5.82 (3.43-9.87), P = < 0.05] variants whereas dominant genotype of ABCC1 rs4148350 [OR 2.52 (1.55-4.10), P = < 0.05] significantly predisposes hepatotoxicity. Furthermore, heterozygous form of ABCG2 rs2231142 [OR 5.25 (1.84-14.95), P = < 0.05] and recessive genotype of 3'UTR variant CBR1 rs9024 [OR 2.31 (1.31-4.07), P = < 0.05] were strongly associated with cardiotoxicity. The information obtained from these genetic variations could offer biomarkers for individualization of therapeutic intervention in ALL.
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Affiliation(s)
- Sara Aslam
- Department of Microbiology and Molecular Genetics, University of the Punjab, Lahore, 54590, Pakistan.
| | - Sonia Ameer
- Department of Microbiology and Molecular Genetics, University of the Punjab, Lahore, 54590, Pakistan
| | - N A Shabana
- Department of Microbiology and Molecular Genetics, University of the Punjab, Lahore, 54590, Pakistan.
| | - Mehboob Ahmed
- Department of Microbiology and Molecular Genetics, University of the Punjab, Lahore, 54590, Pakistan
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11
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Melo MDTD, Paiva MG, Santos MVC, Rochitte CE, Moreira VDM, Saleh MH, Brandão SCS, Gallafrio CC, Goldwasser D, Gripp EDA, Piveta RB, Silva TO, Santo THCE, Ferreira WP, Salemi VMC, Cauduro SA, Barberato SH, Lopes HMC, Pena JLB, Rached HRS, Miglioranza MH, Pinheiro AC, Vrandecic BALM, Cruz CBBV, Nomura CH, Cerbino FME, Costa IBSDS, Coelho Filho OR, Carneiro ACDC, Burgos UMMC, Fernandes JL, Uellendahl M, Calado EB, Senra T, Assunção BL, Freire CMV, Martins CN, Sawamura KSS, Brito MM, Jardim MFS, Bernardes RJM, Diógenes TC, Vieira LDO, Mesquita CT, Lopes RW, Segundo Neto EMV, Rigo L, Marin VLS, Santos MJ, Grossman GB, Quagliato PC, Alcantara MLD, Teodoro JAR, Albricker ACL, Barros FS, Amaral SID, Porto CLL, Barros MVL, Santos SND, Cantisano AL, Petisco ACGP, Barbosa JEM, Veloso OCG, Spina S, Pignatelli R, Hajjar LA, Kalil Filho R, Lopes MACQ, Vieira MLC, Almeida ALC. Brazilian Position Statement on the Use Of Multimodality Imaging in Cardio-Oncology - 2021. Arq Bras Cardiol 2021; 117:845-909. [PMID: 34709307 PMCID: PMC8528353 DOI: 10.36660/abc.20200266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
| | | | | | - Carlos Eduardo Rochitte
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital do Coração (HCOR), São Paulo, SP - Brasil
| | | | - Mohamed Hassan Saleh
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | | | - Daniel Goldwasser
- Hospital Federal de Ipanema, Rio de Janeiro, RJ - Brasil
- Hospital Copa D'Or, Rio de Janeiro, RJ - Brasil
- Casa de Saúde São José, Rio de Janeiro, RJ - Brasil
| | - Eliza de Almeida Gripp
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Hospital Universitário Antônio Pedro, Rio de Janeiro, RJ - Brasil
| | | | - Tonnison Oliveira Silva
- Hospital Cardio Pulmonar - Centro de Estudos em Cardiologia, Salvador, BA - Brasil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
| | | | | | - Vera Maria Cury Salemi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Silvio Henrique Barberato
- CardioEco Centro de Diagnóstico Cardiovascular, Curitiba, PR - Brasil
- Quanta Diagnóstico, Curitiba, PR - Brasil
| | | | | | | | - Marcelo Haertel Miglioranza
- Instituto de Cardiologia do Rio Grande do Sul - Laboratório de Pesquisa e Inovação em Imagem Cardiovascular, Porto Alegre, RS - Brasil
- Hospital Mãe de Deus, Porto Alegre, RS - Brasil
| | | | | | | | - César Higa Nomura
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Fernanda Mello Erthal Cerbino
- Clínica de Diagnóstico por Imagem, Rio de Janeiro, RJ - Brasil
- Diagnósticos da América AS, Rio de Janeiro, RJ - Brasil
| | | | | | | | | | - Juliano Lara Fernandes
- Radiologia Clínica de Campinas, Campinas, SP - Brasil
- Instituto de Ensino e Pesquisa José Michel Kalaf, Campinas, SP - Brasil
| | - Marly Uellendahl
- Diagnósticos da América AS, Rio de Janeiro, RJ - Brasil
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Tiago Senra
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
- Hospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Bruna Leal Assunção
- Universidade de São Paulo Instituto do Câncer do Estado de São Paulo, São Paulo, SP - Brasil
| | - Claudia Maria Vilas Freire
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
- ECOCENTER, Belo Horizonte, MG - Brasil
| | | | - Karen Saori Shiraishi Sawamura
- Hospital do Coração (HCOR), São Paulo, SP - Brasil
- Hospital Universitário Antônio Pedro, Rio de Janeiro, RJ - Brasil
- Instituto da Criança da Universidade de São Paulo (USP), São Paulo, SP - Brasil
| | - Márcio Miranda Brito
- Universidade Federal do Tocantins - Campus de Araguaina, Araguaina, TO - Brasil
- Hospital Municipal de Araguaina, Araguaina, TO - Brasil
| | | | | | | | | | - Claudio Tinoco Mesquita
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Universidade Federal Fluminense (UFF), Rio de Janeiro, RJ - Brasil
- Hospital Vitória, Rio de Janeiro, RJ - Brasil
| | | | | | - Letícia Rigo
- Hospital Beneficência Portuguesa, São Paulo, SP - Brasil
| | | | | | - Gabriel Blacher Grossman
- Clínica Cardionuclear, Porto Alegre, RS - Brasil
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
| | | | - Monica Luiza de Alcantara
- Americas Medical City, Rio de Janeiro, Rio de Janeiro, RJ - Brasil
- Americas Serviços Médicos, Rio de Janeiro, RJ - Brasil
- Rede D'Or, Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Simone Nascimento Dos Santos
- Hospital Brasília - Ecocardiografia, Brasília, DF - Brasil
- Eccos Diagnóstico Cardiovascular Avançado, Brasília, DF - Brasil
| | | | | | | | | | | | - Ricardo Pignatelli
- Texas Children's Hospital, Houston, Texas - EUA
- Baylor College of Medicine, Houston, Texas - EUA
| | - Ludhmilla Abrahão Hajjar
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Universidade de São Paulo Instituto do Câncer do Estado de São Paulo, São Paulo, SP - Brasil
| | - Roberto Kalil Filho
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Universidade de São Paulo Instituto do Câncer do Estado de São Paulo, São Paulo, SP - Brasil
| | - Marcelo Antônio Cartaxo Queiroga Lopes
- Hospital Alberto Urquiza Wanderley - Hemodinâmica e Cardiologia Intervencionista, João Pessoa, PB - Brasil
- Hospital Metropolitano Dom José Maria Pires, João Pessoa, PB - Brasil
- Sociedade Brasileira de Cardiologia, Rio de Janeiro, RJ - Brasil
| | - Marcelo Luiz Campos Vieira
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - André Luiz Cerqueira Almeida
- Santa Casa de Misericórdia de Feira de Santana - Cardiologia, Feira de Santana, BA - Brasil
- Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia, São Paulo, SP - Brasil
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12
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Ansheles AA, Sergienko IV, Prus YA, Sergienko VB. Nuclear imaging of chemotherapy-induced cardiotoxicity. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The high efficiency of modern chemotherapy has made it possible to achieve great success in the treatment of cancer. Cardiovascular adverse effects are a major disadvantage of anticancer therapy, often requiring low and less effective doses or even drug withdrawal. Nuclear imaging techniques are the most sensitive in early detection of left ventricular damage and dysfunction during chemotherapy. This review presents modern data on the potential of nuclear imaging of cardiotoxicity.
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Affiliation(s)
| | | | - Yu. A. Prus
- National Medical Research Center of Cardiology
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13
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Kobat H, Elkonaissi I, Dorak MT, Nabhani-Gebara S. Management of COVID-19 in cancer patients receiving cardiotoxic anti-cancer therapy. Future recommendations for cardio-oncology. Oncol Rev 2021; 15:510. [PMID: 33747366 PMCID: PMC7967496 DOI: 10.4081/oncol.2021.510] [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: 08/14/2020] [Accepted: 01/26/2021] [Indexed: 12/15/2022] Open
Abstract
Cardiotoxicity induced by anti-cancer treatment has become a significant threat as the number of cardiotoxic anti-cancer agents is growing. Cancer patients are at an increased risk of contracting coronavirus disease 2019 (COVID-19) because of immune suppression caused by anti-cancer drugs and/or supportive treatment. Deterioration in lung functions due to COVID-19 is responsible for many cardiac events. The presence of COVID-19 and some of its treatment modalities may increase the chance of cardiotoxicity development in cancer patients receiving potentially cardiotoxic agents. This review provides evidence-based information on the cardiotoxicity risk in cancer patients clinically diagnosed with COVID-19 who are receiving potentially cardiotoxic anti-cancer agents. Proposed strategies relating to the management of this patient cohorts are also discussed.
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Affiliation(s)
- Hasan Kobat
- Department of Pharmacy, School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Penrhyn Road, Kingston Upon Thames
| | - Islam Elkonaissi
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - Mehmet Tevfik Dorak
- Head of School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Penrhyn Road, Kingston Upon Thames, United Kingdom
| | - Shereen Nabhani-Gebara
- Department of Pharmacy, School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Penrhyn Road, Kingston Upon Thames
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14
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Sancho JM, Fernández-Alvarez R, Gual-Capllonch F, González-García E, Grande C, Gutiérrez N, Peñarrubia MJ, Batlle-López A, González-Barca E, Guinea JM, Gimeno E, Peñalver FJ, Fuertes M, Bastos M, Hernández-Rivas JÁ, Moraleda JM, García O, Sorigué M, Martin A. R-COMP versus R-CHOP as first-line therapy for diffuse large B-cell lymphoma in patients ≥60 years: Results of a randomized phase 2 study from the Spanish GELTAMO group. Cancer Med 2021; 10:1314-1326. [PMID: 33492774 PMCID: PMC7926012 DOI: 10.1002/cam4.3730] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/30/2020] [Accepted: 12/24/2020] [Indexed: 12/20/2022] Open
Abstract
The use of non-pegylated liposomal doxorubicin (Myocet® ) in diffuse large B-cell lymphoma (DLBCL) has been investigated in retrospective and single-arm prospective studies. This was a prospective phase 2 trial of DLBCL patients ≥60 years old with left ventricular ejection fraction (LVEF) ≥55% randomized to standard R-CHOP or investigational R-COMP (with Myocet® instead of conventional doxorubicin). The primary end point was to evaluate the differences in subclinical cardiotoxicity, defined as decrease in LVEF to <55% at the end of treatment. Secondary objectives were efficacy, safety, and variations of troponin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) and LVEF along follow-up. Ninety patients were included, 45 in each group. No differences were observed in the percentage of patients with LVEF <55% at end of treatment (11% in R-CHOP arm vs. 7% in R-COMP arm, p = 0.697) or at 4 months (10% vs. 6%, respectively, p = 0.667) and 12 months (8% vs. 7%, respectively, p = 1). However, a higher percentage of R-CHOP compared with R-COMP patients showed increased troponin levels in cycle 6 (100% vs. 63%, p = 0.001) and at 1 month after treatment (88% vs. 56%, respectively, p = 0.015). Cardiovascular adverse events were seen in five R-CHOP patients (nine episodes, four grade ≥3) and in four R-COMP patients (five episodes, all grade 1-2). No significant differences in efficacy were observed. In conclusion, R-COMP is a feasible immunochemotherapy schedule for DLBCL patients ≥60 years, with similar efficacy to R-CHOP. However, the use of non-pegylated doxorubicin instead of conventional doxorubicin was not associated with less early cardiotoxicity, although some reduced cardiac safety signals were observed. Trial registration: ClinicalTrials.gov Identifier: NCT02012088.
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Affiliation(s)
- Juan-Manuel Sancho
- Hematology Department, ICO-IJC-Hospital Germans Trias i Pujol, Badalona, Spain
| | | | | | | | - Carlos Grande
- Hematology Department, Hospital Doce de Octubre, Madrid, Spain
| | - Norma Gutiérrez
- Hematology Department, Hospital Universitario de Salamanca, IBSAL, CIBERONC, Salamanca, Spain
| | | | - Ana Batlle-López
- Hematology Department, Hospital Marqués de Valdecilla, Santander, Spain
| | - Eva González-Barca
- Hematology Department, ICO-Hospital Durán i Reynals (Hospitalet de Llobregat, Barcelona, Spain
| | - José-María Guinea
- Hematology Department, Hospital Universitario de Araba, Vitoria, Spain
| | - Eva Gimeno
- Hematology Department, Hospital del Mar, Barcelona, Spain
| | | | - Miguel Fuertes
- Hematology Department, Hospital Clínico Lozano Blesa, Zaragoza, Spain
| | - Mariana Bastos
- Hematology Department, Hospital Gregorio Marañón, Madrid, Spain
| | | | | | - Olga García
- Hematology Department, ICO-IJC-Hospital Germans Trias i Pujol, Badalona, Spain
| | - Marc Sorigué
- Hematology Department, ICO-IJC-Hospital Germans Trias i Pujol, Badalona, Spain
| | - Alejandro Martin
- Hematology Department, Hospital Universitario de Salamanca, IBSAL, CIBERONC, Salamanca, Spain
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15
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Gonciar D, Mocan L, Zlibut A, Mocan T, Agoston-Coldea L. Cardiotoxicity in HER2-positive breast cancer patients. Heart Fail Rev 2021; 26:919-935. [PMID: 33405000 DOI: 10.1007/s10741-020-10072-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 01/22/2023]
Abstract
Due to the recent advances in diagnosis and management of patients with HER2-positive breast cancer, especially through novel HER2-targeted agents, cardiotoxicity becomes an emerging problem. Although chemotherapy significantly increases survival, the risk of cardiovascular disease development is high and still underestimated and could imply treatment discontinuation. Frequently, due to lack of rigorous diagnosis strategies, cardiotoxicity assessment is delayed, and, moreover, the efficacy of current therapy options in restoring heart function is questionable. For a comprehensive risk assessment, it is vital to characterize the clinical spectrum of HER2-targeted agents and anthracyclines, as well as their pathogenic pathways involved in cardiotoxicity. Advanced cardiovascular multimodal imaging and circulating biomarkers plays primary roles in early assessing cardiotoxicity and also in guiding specific preventive measures. Even though the knowledge in this field is rapidly expanding, there are still questions that arise regarding the optimal approach in terms of timing and methods. The aim of the current review aims to providean overview of currently available data.
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Affiliation(s)
- Diana Gonciar
- 2nd Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Lucian Mocan
- 3rd Surgery Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Nanomedicine, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Alexandru Zlibut
- 2nd Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Teodora Mocan
- Physiology Department, Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Nanomedicine, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Lucia Agoston-Coldea
- 2nd Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
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16
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Onishi T, Fukuda Y, Miyazaki S, Yamada H, Tanaka H, Sakamoto J, Daimon M, Izumi C, Nonaka A, Nakatani S, Akaishi M. Practical guidance for echocardiography for cancer therapeutics-related cardiac dysfunction. J Echocardiogr 2020; 19:1-20. [PMID: 33159650 PMCID: PMC7932955 DOI: 10.1007/s12574-020-00502-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 01/06/2023]
Abstract
The prognosis of patients with cancer has improved due to an early diagnosis of cancer and advances in cancer treatment. There are emerging reports on cardiotoxicity in cancer treatment and on cardiovascular disease in cancer patients, from which cardiovascular disease has been recognized as a common cause of death among cancer survivors. This situation has led to the need for a medical system in which oncologists and cardiologists work together to treat patients. With the growing importance of onco-cardiology, the role of echocardiography in cancer care is rapidly expanding, but at present, the practice of echocardiography in clinical settings varies from institution to institution, and is empirical with no established systematic guidance. In view of these circumstances, we thought that brief guidance for clinical application was necessary and have therefore developed this guidance, although evidence in this field is still insufficient.
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Affiliation(s)
| | | | | | | | | | | | | | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, Suita, Osaka, Japan.
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17
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Abstract
Remarkable progress has been made in the development of new therapies for cancer, dramatically changing the landscape of treatment approaches for several malignancies and continuing to increase patient survival. Accordingly, adverse effects of cancer therapies that interfere with the continuation of best-possible care, induce life-threatening risks or lead to long-term morbidity are gaining increasing importance. Cardiovascular toxic effects of cancer therapeutics and radiation therapy are the epitome of such concerns, and proper knowledge, interpretation and management are needed and have to be placed within the context of the overall care of individual patients with cancer. Furthermore, the cardiotoxicity spectrum has broadened to include myocarditis with immune checkpoint inhibitors and cardiac dysfunction in the setting of cytokine release syndrome with chimeric antigen receptor T cell therapy. An increase in the incidence of arrhythmias related to inflammation such as atrial fibrillation can also be expected, in addition to the broadening set of cancer therapeutics that can induce prolongation of the corrected QT interval. Therefore, cardiologists of today have to be familiar not only with the cardiotoxicity associated with traditional cancer therapies, such as anthracycline, trastuzumab or radiation therapy, but even more so with an ever-increasing repertoire of therapeutics. This Review provides this information, summarizing the latest developments at the juncture of cardiology, oncology and haematology.
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Affiliation(s)
- Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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18
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Planek MIC, Manshad A, Hein K, Hemu M, Ballout F, Varandani R, Venugopal P, Okwuosa T. Prediction of doxorubicin cardiotoxicity by early detection of subclinical right ventricular dysfunction. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2020; 6:10. [PMID: 32714566 PMCID: PMC7376704 DOI: 10.1186/s40959-020-00066-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/15/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Doxorubicin remains one of the most common causes of cardiotoxicity in patients with lymphoma, leading to significant morbidity and mortality. Early decline in left ventricular (LV) ejection fraction predicts chemotherapy-induced cardiotoxicity and mortality, but limited data exist on doxorubicin-induced subclinical right ventricular (RV) dysfunction. We investigated dose-dependent subclinical doxorubicin-induced RV dysfunction in lymphoma patients. METHODS Thirty-five patients with adult lymphoma treated with doxorubicin were studied. All patients had normal baseline LV ejection fraction (LVEF > 55%), and no known cardiopulmonary disease. We studied the dose-dependent effect of doxorubicin on RV strain by 2D speckle-tracking echocardiography (STE) using a vendor-independent software (TomTec). Images were analyzed offline by two independent observers blinded to the clinical characteristics of the study population. Baseline LVEF, RV fractional area change (RV FAC), RV free wall strain (RV FWS), and RV global longitudinal strain (RV GLS) were measured prior to chemotherapy initiation and compared with echo studies obtained at a 6-month follow-up interval. Patients served as their own controls. Comparisons between pre- and post-therapy were achieved using paired Student's t-tests or Chi-Square test. RESULTS The Interobserver Intraclass Correlation Coefficient for RV GLS, RV FAC and RV FWS, was 0.87, 0.81 and 0.79, respectively. The mean age was 51 ± 13 years, 40% women, 60% white. The mean cumulative doxorubicin dose was 239 ± 104 mg m- 2. There was there was significant decline in RV FAC (47.3 ± 4.4% vs. 43.7 ± 3.9%), RV FWS (- 24.9 ± 3.3 vs. -22.2 ± 2.9), and RV GLS (- 22.4 ± 4.1 vs. -20.6 ± 3.4) (all p < 0.01); but no significant decline in LVEF during the 6-month follow up (63.3 ± 6.2% vs. 61.6 ± 11.1%, p = 0.374). At cumulative doxorubicin dose ≥200 mg m- 2 we found a significant decline in RV FAC (47.0 ± 4.7% vs. 42.2 ± 3.1%, p < 0.01), RV FWS (- 24.6 ± 3.6 vs. -21.5 ± 2.4, p < 0.01), and RV GLS (- 22.3 ± 4.5 vs. -20.1 ± 2.9, p = 0.03). CONCLUSION In this cohort of adult lymphoma patients, doxorubicin-based therapy was associated with subclinical RV dysfunction, but not LV dysfunction, at a cumulative dose ≥200 mg m- 2. Additional studies evaluating the long-term prognostic implications of RV dysfunction in this population are essential.
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Affiliation(s)
| | - Ahmad Manshad
- Division of Cardiology, Loyola University Medical Center, Maywood, IL 60153 USA
| | - Kyaw Hein
- Department of Medicine, Rush University Medical Center, Chicago, IL 60612 USA
| | - Mohamad Hemu
- Department of Medicine, Rush University Medical Center, Chicago, IL 60612 USA
| | - Fatima Ballout
- Division of Nephrology, Rush University Medical Center, Chicago, IL 60612 USA
| | - Rajiv Varandani
- Chicago College of Osteopathic Medicine at Midwestern University, Downers Grove, IL 60515 USA
| | | | - Tochukwu Okwuosa
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612 USA
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19
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Christidi E, Huang H, Shafaattalab S, Maillet A, Lin E, Huang K, Laksman Z, Davis MK, Tibbits GF, Brunham LR. Variation in RARG increases susceptibility to doxorubicin-induced cardiotoxicity in patient specific induced pluripotent stem cell-derived cardiomyocytes. Sci Rep 2020; 10:10363. [PMID: 32587261 PMCID: PMC7316788 DOI: 10.1038/s41598-020-65979-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/11/2020] [Indexed: 01/04/2023] Open
Abstract
Doxorubicin is a potent anticancer drug used to treat a variety of cancer types. However, its use is limited by doxorubicin-induced cardiotoxicity (DIC). A missense variant in the RARG gene (S427L; rs2229774) has been implicated in susceptibility to DIC in a genome wide association study. The goal of this study was to investigate the functional role of this RARG variant in DIC. We used induced pluripotent stem cell derived cardiomyocytes (iPSC-CMs) from patients treated with doxorubicin. iPSC-CMs from individuals who experienced DIC (cases) showed significantly greater sensitivity to doxorubicin compared to iPSC-CMs from doxorubicin-treated individuals who did not develop DIC (controls) in cell viability and optical mapping experiments. Using CRISPR/Cas9, we generated isogenic cell lines that differed only at the RARG locus. Genetic correction of RARG-S427L to wild type resulted in reduced doxorubicin-induced double stranded DNA breaks, reactive oxygen species production, and cell death. Conversely, introduction of RARG-S427L increased susceptibility to doxorubicin. Finally, genetic disruption of the RARG gene resulted in protection from cell death due to doxorubicin treatment. Our findings suggest that the presence of RARG-S427L increases sensitivity to DIC, establishing a direct, causal role for this variant in DIC.
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Affiliation(s)
- Effimia Christidi
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Haojun Huang
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Sanam Shafaattalab
- Molecular Cardiac Physiology Group, Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
- Department of Cardiovascular Science, British Columbia Children's Hospital, Vancouver, Canada
| | | | - Eric Lin
- Molecular Cardiac Physiology Group, Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
| | - Kate Huang
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Zachary Laksman
- Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Margot K Davis
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Glen F Tibbits
- Molecular Cardiac Physiology Group, Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
- Department of Cardiovascular Science, British Columbia Children's Hospital, Vancouver, Canada
| | - Liam R Brunham
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, Canada.
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada.
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20
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Berliner D, Beutel G, Bauersachs J. Echocardiography and biomarkers for the diagnosis of cardiotoxicity. Herz 2020; 45:637-644. [DOI: 10.1007/s00059-020-04957-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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21
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Kahanda MG, Hanson CA, Patterson B, Bourque JM. Nuclear cardio-oncology: From its foundation to its future. J Nucl Cardiol 2020; 27:511-518. [PMID: 30788760 DOI: 10.1007/s12350-019-01655-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 01/31/2019] [Indexed: 11/26/2022]
Abstract
Cardio-oncology is a growing field focused on the prevention and treatment of cardiovascular disease in oncologic patients. While a major focus of chemotherapy-related cardiac dysfunction has been on left ventricular ejection fraction, oncologic treatment can lead to cardiovascular pathology in a variety of ways. The use of multimodality imaging is essential to the care of these patients, with nuclear cardiology playing an important role. We will review nuclear cardiology's history, its current role, and its promising future in cardio-oncology and the management of these patients.
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Affiliation(s)
- Milan G Kahanda
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Box 800158, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Christopher A Hanson
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Box 800158, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Brandy Patterson
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Box 800158, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Box 800158, 1215 Lee Street, Charlottesville, VA, 22908, USA.
- Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA.
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22
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Curigliano G, Lenihan D, Fradley M, Ganatra S, Barac A, Blaes A, Herrmann J, Porter C, Lyon AR, Lancellotti P, Patel A, DeCara J, Mitchell J, Harrison E, Moslehi J, Witteles R, Calabro MG, Orecchia R, de Azambuja E, Zamorano JL, Krone R, Iakobishvili Z, Carver J, Armenian S, Ky B, Cardinale D, Cipolla CM, Dent S, Jordan K. Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations. Ann Oncol 2020; 31:171-190. [PMID: 31959335 PMCID: PMC8019325 DOI: 10.1016/j.annonc.2019.10.023] [Citation(s) in RCA: 515] [Impact Index Per Article: 128.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/13/2022] Open
Abstract
Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.
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Affiliation(s)
- G. Curigliano
- European Institute of Oncology IRCCS, Milan
- Department of Oncology and Haematology (DIPO), University of Milan, Milan, Italy
| | - D. Lenihan
- Cardiovascular Division, Cardio-Oncology Center of Excellence, Washington University Medical Center, St. Louis
| | - M. Fradley
- Cardio-oncology Program, Division of Cardiovascular Medicine, Morsani College of Medicine and H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa
| | - S. Ganatra
- Cardio-Oncology Program, Lahey Medical Center, Burlington
| | - A. Barac
- Cardio-Oncology Program, Medstar Heart and Vascular Institute and MedStar Georgetown Cancer Institute, Georgetown University Hospital, Washington DC
| | - A. Blaes
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis
| | | | - C. Porter
- University of Kansas Medical Center, Lawrence, USA
| | - A. R. Lyon
- Royal Brompton Hospital and Imperial College, London, UK
| | - P. Lancellotti
- GIGA Cardiovascular Sciences, Acute Care Unit, Heart Failure Clinic, CHU Sart Tilman, University Hospital of Liège, Liège, Belgium
| | - A. Patel
- Morsani College of Medicine, University of South Florida, Tampa
| | - J. DeCara
- Medicine Section of Cardiology, University of Chicago, Chicago
| | - J. Mitchell
- Washington University Medical Center, St. Louis
| | - E. Harrison
- HCA Memorial Hospital and University of South Florida, Tampa
| | - J. Moslehi
- Vanderbilt University School of Medicine, Nashville
| | - R. Witteles
- Division of Cardiovascular Medicine, Falk CVRC, Stanford University School of Medicine, Stanford, USA
| | - M. G. Calabro
- Department of Anesthesia and Intensive Care, IRCCS, San Raffaele Scientific Institute, Milan, Italy
| | | | - E. de Azambuja
- Institut Jules Bordet and L’Université Libre de Bruxelles, Brussels, Belgium
| | | | - R. Krone
- Division of Cardiology, Washington University, St. Louis, USA
| | - Z. Iakobishvili
- Clalit Health Services, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J. Carver
- Division of Cardiology, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia
| | - S. Armenian
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte
| | - B. Ky
- University of Pennsylvania School of Medicine, Philadelphia, USA
| | - D. Cardinale
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan
| | - C. M. Cipolla
- Cardiology Department, European Institute of Oncology, IRCCS, Milan, Italy
| | - S. Dent
- Duke Cancer Institute, Duke University, Durham, USA
| | - K. Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - ESMO Guidelines Committee
- Correspondence to: ESMO Guidelines Committee, ESMO Head Office, Via Ginevra 4, CH-6900 Lugano, Switzerland, (ESMO Guidelines Committee)
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23
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Zeng ZM, Xu P, Zhou S, Du HY, Jiang XL, Cai J, Huang L, Liu AW. Positive association between heart dosimetry parameters and a novel cardiac biomarker, solubleST-2, in thoracic cancer chest radiation. J Clin Lab Anal 2020; 34:e23150. [PMID: 31923333 PMCID: PMC7171349 DOI: 10.1002/jcla.23150] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 12/11/2022] Open
Abstract
Background Early screening and diagnosis of radiation‐induced heart disease (RIHD) is difficult in patients with chest radiation exposure. sST‐2 is involved in myocardial stress or injury. We evaluated the relationship between heart dose parameters and sST‐2 changes in chest malignant tumor patients who received chest radiation. Methods We prospectively collected thoracic malignancy cancer patients who had received chest radiotherapy. Heart dosimetry parameters were extracted from the treatment planning system. sST‐2 was measured at baseline, the middle stage, and after radiotherapy (recorded as pre‐ST‐2, mid‐ST‐2, and post‐ST‐2). sST‐2 change rate was calculated. Scatter plots showed the relationship between cardiac dose parameters and ST‐2 change rate. Multiple regression was used to analyze the relationship between cardiac dose parameters and ST‐2 change rate. Results Totally, 60 patients were enrolled. The mean V5, V10, V20, V30, V40, and MHD was 60.93 ± 27.79%, 51.43 ± 25.44%, 39.17 ± 21.75%, 28.07 ± 17.15%,18.66 ± 12.18%, and 18.60 ± 8.63 Gy, respectively. The median M‐LAD was 11.31 (IQR 3.33‐18.76) Gy. The mean pre‐ST‐2, mid‐ST‐2, and post‐ST‐2 was 5.1 ± 3.8, 6.4 ± 3.9, and 7.6 ± 4.4, respectively. sST‐2 was elevated with thoracic irradiation (P < .001). Multivariate linear regression analyses showed that V5, V10, V20, and MHD were independently and positively associated with ST‐2 change rate (β = .04, .04, .04, and .10, respectively, all P < .05). Conclusion Serum sST‐2 levels were elevated over time during radiotherapy. V5, V10, V20 and MHD were independently and positively associated with the elevated ST‐2 change rate.
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Affiliation(s)
- Zhi-Min Zeng
- Department of Oncology, The second affiliated hospital of Nanchang University, Nanchang, China.,Jiangxi key laboratory of clinical translational cancer research, The second affiliated hospital of Nanchang University, Nanchang, China
| | - Peng Xu
- Department of Oncology, The second affiliated hospital of Nanchang University, Nanchang, China.,Jiangxi key laboratory of clinical translational cancer research, The second affiliated hospital of Nanchang University, Nanchang, China
| | - Shan Zhou
- Department of Oncology, The second affiliated hospital of Nanchang University, Nanchang, China
| | - Hai-Yang Du
- Department of Oncology, The second affiliated hospital of Nanchang University, Nanchang, China
| | - Xiao-Liu Jiang
- Department of Oncology, The second affiliated hospital of Nanchang University, Nanchang, China
| | - Jing Cai
- Department of Oncology, The second affiliated hospital of Nanchang University, Nanchang, China
| | - Long Huang
- Department of Oncology, The second affiliated hospital of Nanchang University, Nanchang, China.,Jiangxi key laboratory of clinical translational cancer research, The second affiliated hospital of Nanchang University, Nanchang, China
| | - An-Wen Liu
- Department of Oncology, The second affiliated hospital of Nanchang University, Nanchang, China.,Jiangxi key laboratory of clinical translational cancer research, The second affiliated hospital of Nanchang University, Nanchang, China
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24
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Hall SE, Smuder AJ, Hayward R. Effects of Calorie Restriction and Voluntary Exercise on Doxorubicin-Induced Cardiotoxicity. Integr Cancer Ther 2019; 18:1534735419843999. [PMID: 30999765 PMCID: PMC6475835 DOI: 10.1177/1534735419843999] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Introduction: Doxorubicin (DOX) is a widely used chemotherapeutic agent with known cardiotoxic properties, while calorie restriction (CR) and exercise have well-documented cardioprotective effects. No studies have investigated the effects of CR alone or the combined effects of CR and exercise on DOX cardiotoxicity. Methods: Rats were divided into 4 groups based on their food intake (ad libitum or CR) and activity (sedentary or voluntary wheel running [WR]). After completing a 16-week treatment, animals received either DOX (15 mg/kg) or saline (SAL) and cardiac function was measured 5 days after treatment. Chromatography was used to quantify left ventricular DOX accumulation. Results: Left ventricular developed pressure (LVDP), end systolic pressure (ESP), and left ventricular maximal rate of pressure development (dP/dtmax) were significantly higher in the CR + DOX group when compared with DOX. Fractional shortening, LVDP, ESP, dP/dtmax, and dP/dtmin were significantly higher in the CR + WR + DOX group compared with the DOX group. In addition, the CR + WR + DOX group showed significantly higher LVDP and ESP compared with the WR + DOX group. DOX accumulation in the heart was 5-fold lower (P < .05) in the CR + WR + DOX group compared with the DOX group. Conclusion: This is the first study to demonstrate that CR can reduce cardiac DOX accumulation, and confirms the protective role of CR against DOX-induced cardiac dysfunction. Our data also show that combining a known cardioprotective intervention, exercise training, with CR results in additive benefits in the protection against DOX cardiotoxicity.
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Affiliation(s)
| | | | - Reid Hayward
- 3 University of Northern Colorado, Greeley, CO, USA
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25
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Croft AJ, Ngo DTM, Sverdlov AL. Anthracycline-Induced Cardiotoxicity: Time to Focus on Cardioprotection Again. Heart Lung Circ 2019; 28:1454-1456. [PMID: 31495502 DOI: 10.1016/j.hlc.2019.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A J Croft
- Faculty of Health and Medicine, The University of Newcastle, NSW and Cardio-oncology Research Group, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - D T M Ngo
- Faculty of Health and Medicine, The University of Newcastle, NSW and Cardio-oncology Research Group, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - A L Sverdlov
- Faculty of Health and Medicine, The University of Newcastle, NSW and Cardio-oncology Research Group, Hunter Medical Research Institute, Newcastle, NSW, Australia; Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia.
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26
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Seraphim A, Westwood M, Bhuva AN, Crake T, Moon JC, Menezes LJ, Lloyd G, Ghosh AK, Slater S, Oakervee H, Manisty CH. Advanced Imaging Modalities to Monitor for Cardiotoxicity. Curr Treat Options Oncol 2019; 20:73. [PMID: 31396720 PMCID: PMC6687672 DOI: 10.1007/s11864-019-0672-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Early detection and treatment of cardiotoxicity from cancer therapies is key to preventing a rise in adverse cardiovascular outcomes in cancer patients. Over-diagnosis of cardiotoxicity in this context is however equally hazardous, leading to patients receiving suboptimal cancer treatment, thereby impacting cancer outcomes. Accurate screening therefore depends on the widespread availability of sensitive and reproducible biomarkers of cardiotoxicity, which can clearly discriminate early disease. Blood biomarkers are limited in cardiovascular disease and clinicians generally still use generic screening with ejection fraction, based on historical local expertise and resources. Recently, however, there has been growing recognition that simple measurement of left ventricular ejection fraction using 2D echocardiography may not be optimal for screening: diagnostic accuracy, reproducibility and feasibility are limited. Modern cancer therapies affect many myocardial pathways: inflammatory, fibrotic, metabolic, vascular and myocyte function, meaning that multiple biomarkers may be needed to track myocardial cardiotoxicity. Advanced imaging modalities including cardiovascular magnetic resonance (CMR), computed tomography (CT) and positron emission tomography (PET) add improved sensitivity and insights into the underlying pathophysiology, as well as the ability to screen for other cardiotoxicities including coronary artery, valve and pericardial diseases resulting from cancer treatment. Delivering screening for cardiotoxicity using advanced imaging modalities will however require a significant change in current clinical pathways, with incorporation of machine learning algorithms into imaging analysis fundamental to improving efficiency and precision. In the future, we should aspire to personalized rather than generic screening, based on a patient’s individual risk factors and the pathophysiological mechanisms of the cancer treatment they are receiving. We should aspire that progress in cardiooncology is able to track progress in oncology, and to ensure that the current ‘one size fits all’ approach to screening be obsolete in the very near future.
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Affiliation(s)
- Andreas Seraphim
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK
| | - Mark Westwood
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Anish N Bhuva
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK
| | - Tom Crake
- Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - James C Moon
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK
| | - Leon J Menezes
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Guy Lloyd
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Arjun K Ghosh
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Sarah Slater
- Department of Haematology, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Heather Oakervee
- Department of Oncology, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Charlotte H Manisty
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK. .,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK. .,Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.
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27
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Pandey S, Kuo W, Ho T, Yeh Y, Shen C, Chen R, Chang R, Pai P, Padma VV, Huang C, Huang C. Upregulation of IGF‐IIRα intensifies doxorubicin‐induced cardiac damage. J Cell Biochem 2019; 120:16956-16966. [PMID: 31104312 DOI: 10.1002/jcb.28957] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/09/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Sudhir Pandey
- Graduate Institute of Biomedical Sciences College of Medicine, China Medical University Taichung Taiwan
| | - Wei‐Wen Kuo
- Department of Biological Science and Technology China Medical University Taichung Taiwan
| | - Tsung‐Jung Ho
- Department of Chinese Medicine Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University Hualien Taiwan
| | - Yu‐Lan Yeh
- Department of Pathology Changhua Christian Hospital Changhua Taiwan
- Department of Nursing and Management Jen‐Teh Junior College of Medicine Miaoli Taiwan
| | - Chia‐Yao Shen
- Department of Nursing Mei Ho University, Pingguang Road Pingtung Taiwan
| | - Ray‐Jade Chen
- Department of Surgery School of Medicine, College of Medicine, Taipei Medical University Taipei Taiwan
| | - Ruey‐Lin Chang
- Department of Postbaccalaureate Chinese Medicine College of Chinese Medicine, China Medical University Taichung Taiwan
| | - Pei‐Ying Pai
- Division of Cardiology China Medical University Hospital Taichung Taiwan
| | - V. Vijaya Padma
- Department of Biotechnology Bharathiar University Coimbatore India
| | - Chih‐Yang Huang
- Department of Translation Research Core China Medical University Hospital Taichung Taiwan
| | - Chih‐Yang Huang
- Graduate Institute of Biomedical Sciences College of Medicine, China Medical University Taichung Taiwan
- Department of Chinese Medicine Graduate Institute of Chinese Medical Science, China Medical University Taichung Taiwan
- Department of Biotechnology Asia University Taichung Taiwan
- School of Medicine Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University Hualien Taiwan
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28
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Demissei BG, Finkelman BS, Hubbard RA, Zhang L, Smith AM, Sheline K, McDonald C, Narayan HK, Narayan V, Waxman AJ, Domchek SM, DeMichele A, Shah P, Clark AS, Bradbury AR, Carver JR, Upshaw J, Armenian SH, Liu P, Ky B. Detailed phenotyping reveals distinct trajectories of cardiovascular function and symptoms with exposure to modern breast cancer therapy. Cancer 2019; 125:2762-2771. [PMID: 31042319 DOI: 10.1002/cncr.32149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/21/2019] [Accepted: 02/11/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Breast cancer therapies are associated with a risk of cardiac dysfunction, most commonly defined by changes in left ventricular ejection fraction (LVEF). Recently, the authors identified 3 classes of LVEF change after exposure to anthracyclines and/or trastuzumab using latent class growth modeling. The objective of the current study was to characterize the clinical, biochemical, and functional profiles associated with LVEF trajectory class membership. METHODS Transthoracic echocardiography and biomarker assessments were performed and questionnaires were administered at standardized intervals in a longitudinal cohort of 314 patients with breast cancer who were treated with anthracyclines and/or trastuzumab. Univariable and multivariable multinomial regression analyses evaluated associations between baseline variables and LVEF trajectory class membership. Generalized estimating equations were used to define mean changes in cardiovascular measures over time within each class. RESULTS Among the 3 distinct subgroups of LVEF changes identified (stable [class 1]; modest, persistent decline [class 2]; and significant early decline followed by partial recovery [class 3]), higher baseline LVEF, radiotherapy, and sequential therapy with anthracyclines and/or trastuzumab were associated with class 2 or 3 membership. Sustained abnormalities in longitudinal strain and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were observed in patients in class 2, as were heart failure symptoms. Similar abnormalities were observed in patients in class 3, but there was a trend toward recovery, particularly for longitudinal strain. CONCLUSIONS Patients with modest, persistent LVEF declines experienced sustained abnormalities in imaging and biochemical markers of cardiac function and heart failure symptoms. Further investigation is needed to characterize the long-term risk of heart failure, particularly in those with modest LVEF declines.
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Affiliation(s)
- Biniyam G Demissei
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian S Finkelman
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Liyong Zhang
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Amanda M Smith
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karyn Sheline
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caitlin McDonald
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hari K Narayan
- Division of Cardiology, Department of Pediatrics, Rady Children's Hospital-San Diego, The University of California at San Diego, San Diego, California
| | - Vivek Narayan
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam J Waxman
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan M Domchek
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela DeMichele
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Payal Shah
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy S Clark
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angela R Bradbury
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph R Carver
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jenica Upshaw
- Division of Cardiology, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, California
| | - Peter Liu
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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29
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Skubitz KM. Cardiotoxicity Monitoring in Patients Treated with Tyrosine Kinase Inhibitors. Oncologist 2019; 24:e600-e602. [PMID: 30971480 DOI: 10.1634/theoncologist.2018-0891] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/06/2019] [Indexed: 11/17/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) can cause cardiotoxicity, and some suggest routine monitoring of cardiac function during TKI use. We describe two cases of TKI-induced heart failure (HF) that suggest the utility of monitoring with laboratory tests is questionable. One patient developed HF 5 days after starting pazopanib. The other developed HF while receiving 25 mg per day sunitinib, and had previously received a higher dose (50 mg per day) with no symptoms of cardiotoxicy. In addition, she later received 5 cycles of sunitinib (25 mg per day) without developing an abnormal left ventricular ejection fraction (LVEF) value by echocardiography or cardiac symptoms. Although the LVEF is commonly performed to monitor TKI cardiotoxicity, evidence for its predictive utility is limited. These cases raise questions regarding the practical utility of sequential measurement of LVEF in adults treated with TKIs. We suggest a simple daily activity such as stair climbing to monitor exercise tolerance.
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Affiliation(s)
- Keith M Skubitz
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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30
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Kibudde S, Mondo CK, Kibirige D, Walusansa V, Orem J. Anthracycline induced cardiotoxicity in adult cancer patients: a prospective cohort study from a specialized oncology treatment centre in Uganda. Afr Health Sci 2019; 19:1647-1656. [PMID: 31148994 PMCID: PMC6531975 DOI: 10.4314/ahs.v19i1.40] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To determine the cumulative incidence of anthracycline induced cardiotoxicity (AIC), its predictors, and associated electrocardiographic and echocardiographic manifestations in adult cancer patients at Uganda Cancer Institute (UCI). METHODS We enrolled 160 participants between June 2013 and April 2014 and followed them up for a median of 146 days. Data on clinical, electrocardiographic and echocardiographic findings was obtained at baseline, and at completion of chemotherapy. The Pearson chi square test was used to identify the predictors associated with cardiotoxicity. RESULTS Of the 64 patients who were accessible for follow-up electrocardiography (ECG) and echocardiography (ECHO), fourteen participants developed cardiotoxicity hence a cumulative incidence rate of 21.9% with 95% CI 13.5%-33.43%. The predictors of AIC were female gender (p=0.025), LVEF (p=0.014) and LVFS (P=0.019). Anthracycline therapy was associated with shortening of the QRS duration (84.3±7.9 Vs 82.1±11.8 ms, p=0.005), prolongation of the QTc interval (411.9±30.7 Vs 447.2±39.4 ms, p=<0.001) and reduction in the LVEF (66.4±7.7 Vs 63.9±8.4%, p=0.026) and LVFS (36.9±6.2 Vs 35.1±6.6%, p=0.03). CONCLUSION The cumulative incidence of AIC in this study cohort was high. Our findings emphasize the need for early monitoring for AIC.
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Affiliation(s)
| | | | | | | | - Jackson Orem
- Uganda Cancer Institute, Department of Medical Oncology
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Attenuation of doxorubicin-induced cardiotoxicity in a human in vitro cardiac model by the induction of the NRF-2 pathway. Biomed Pharmacother 2019; 112:108637. [PMID: 30798127 DOI: 10.1016/j.biopha.2019.108637] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 01/06/2023] Open
Abstract
Dose-dependent cardiotoxicity is the leading adverse reaction seen in cancer patients treated with doxorubicin. Currently, dexrazoxane is the only approved drug that can partially protect against this toxicity in patients, however, its administration is restricted to those patients receiving a high cumulative dose of anthracyclines. Investigations into the mechanisms of cardiotoxicity and efforts to improve cardioprotective strategies have been hindered by the limited availability of a phenotypically relevant in vitro adult human cardiac model system. Here, we adapted a readily reproducible, functional 3D human multi-cell type cardiac system to emulate patient responses seen with doxorubicin and dexrazoxane. We show that administration of two NRF2 gene inducers namely the semi-synthetic triterpenoid Bardoxolone methyl, and the isothiocyanate sulfurophane, result in cardioprotection against doxorubicin toxicity comparable to dexrazoxane as evidenced by an increase in cell viability and a decrease in the production of reactive oxygen species. We further show a synergistic attenuation of cardiotoxicity when the NRF2 inducers and dexrazoxane are used in tandem. Taken together, our data indicate that the 3D spheroid is a suitable model to investigate drug induced cardiotoxicity and we reveal an essential role of the NRF2 pathway in cardioprotection providing a novel pharmacological mechanism and intervention route towards the alleviation of doxorubicin-induced toxicity.
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Prusila REI, Peroja P, Jantunen E, Turpeenniemi-Hujanen T, Kuittinen O. Treatment of diffuse large B-cell lymphoma in elderly patients: Replacing doxorubicin with either epirubicin or etoposide (VP-16). Hematol Oncol 2019; 37:136-142. [PMID: 30589950 DOI: 10.1002/hon.2572] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/07/2018] [Accepted: 12/21/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Roosa Enni Inkeri Prusila
- Cancer and Translational Medicine Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Oncology and Radiotherapy, Oulu University Hospital, Oulu, Finland
| | - Pekka Peroja
- Cancer and Translational Medicine Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Oncology and Radiotherapy, Oulu University Hospital, Oulu, Finland
| | - Esa Jantunen
- Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Medicine, Kuopio University Hospital, Kuopio, Finland.,Siunsote - Hospital District of North Carelia, Joensuu, Finland
| | - Taina Turpeenniemi-Hujanen
- Cancer and Translational Medicine Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Oncology and Radiotherapy, Oulu University Hospital, Oulu, Finland
| | - Outi Kuittinen
- Department of Oncology and Radiotherapy, Oulu University Hospital, Oulu, Finland.,Faculty of Health Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Oncology, Kuopio University Hospital, Kuopio, Finland
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Saleh T, Al-Rubaye A, Noori A, Ibrahim I. Assessment of anthracycline-induced long-term cardiotoxicity in patients with hematological malignancies. IRAQI JOURNAL OF HEMATOLOGY 2019. [DOI: 10.4103/ijh.ijh_4_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Xie X, Tang F, Liu G, Li Y, Su X, Jiao X, Wang X, Tang B. Mitochondrial Peroxynitrite Mediation of Anthracycline-Induced Cardiotoxicity as Visualized by a Two-Photon Near-Infrared Fluorescent Probe. Anal Chem 2018; 90:11629-11635. [DOI: 10.1021/acs.analchem.8b03207] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Xilei Xie
- College of Chemistry, Chemical Engineering and Materials Science, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Institute of Molecular and Nano Science, Shandong Normal University, Jinan 250014, PR China
| | - Fuyan Tang
- College of Chemistry, Chemical Engineering and Materials Science, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Institute of Molecular and Nano Science, Shandong Normal University, Jinan 250014, PR China
| | - Guangzhao Liu
- College of Chemistry, Chemical Engineering and Materials Science, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Institute of Molecular and Nano Science, Shandong Normal University, Jinan 250014, PR China
| | - Yong Li
- College of Chemistry, Chemical Engineering and Materials Science, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Institute of Molecular and Nano Science, Shandong Normal University, Jinan 250014, PR China
| | - Xingxing Su
- College of Chemistry, Chemical Engineering and Materials Science, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Institute of Molecular and Nano Science, Shandong Normal University, Jinan 250014, PR China
| | - Xiaoyun Jiao
- College of Chemistry, Chemical Engineering and Materials Science, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Institute of Molecular and Nano Science, Shandong Normal University, Jinan 250014, PR China
| | - Xu Wang
- College of Chemistry, Chemical Engineering and Materials Science, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Institute of Molecular and Nano Science, Shandong Normal University, Jinan 250014, PR China
| | - Bo Tang
- College of Chemistry, Chemical Engineering and Materials Science, Key Laboratory of Molecular and Nano Probes, Ministry of Education, Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong, Institute of Molecular and Nano Science, Shandong Normal University, Jinan 250014, PR China
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35
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Yu LR, Cao Z, Makhoul I, Daniels JR, Klimberg S, Wei JY, Bai JP, Li J, Lathrop JT, Beger RD, Todorova VK. Immune response proteins as predictive biomarkers of doxorubicin-induced cardiotoxicity in breast cancer patients. Exp Biol Med (Maywood) 2017; 243:248-255. [PMID: 29224368 DOI: 10.1177/1535370217746383] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Cancer treatment with doxorubicin (DOX) can induce cumulative dose-dependent cardiotoxicity. Currently, there are no specific biomarkers that can identify patients at risk during the initial doses of chemotherapy. The aim of this study was to examine plasma cytokines/chemokines and potential cardiovascular biomarkers for the prediction of DOX-induced cardiotoxicity. Plasma samples were collected before (T0), and after the first (T1) and the second (T2) cycles of DOX-based chemotherapy of 27 breast cancer patients, including five patients who presented with >10% decline of left ventricular ejection fraction (LVEF), five patients with LVEF decline of 5-10%, and 17 patients who maintained normal LVEF at the end of chemotherapy (240 mg/m2 cumulative dose of DOX from four cycles of treatment). Multiplex immunoassays were used to screen plasma samples for 40 distinct chemokines, nine matrix metalloproteinases, 33 potential markers of cardiovascular diseases, and the fourth-generation cardiac troponin T assay. The results showed that the patients with abnormal decline of LVEF (>10%) had lower levels of CXCL6 and sICAM-1 and higher levels of CCL23 and CCL27 at T0; higher levels of CCL23 and lower levels of CXCL5, CCL26, CXCL6, GM-CSF, CXCL1, IFN-γ, IL-2, IL-8, CXCL11, CXCL9, CCL17, and CCL25 at T1; and higher levels of MIF and CCL23 at T2 than the patients who maintained normal LVEF. Patients with LVEF decline of 5-10% had lower plasma levels of CXCL1, CCL3, GDF-15, and haptoglobin at T0; lower levels of IL-16, FABP3, and myoglobin at T1; and lower levels of myoglobin and CCL23 at T2 as compared to the patients who maintained normal LVEF. This pilot study identified potential biomarkers that may help predict which patients are vulnerable to DOX-induced cardiotoxicity although further validation is needed in a larger cohort of patients. Impact statement Drug-induced cardiotoxicity is one of the major concerns in drug development and clinical practice. It is critical to detect potential cardiotoxicity early before onset of symptomatic cardiac dysfunction or heart failure. Currently there are no qualified clinical biomarkers for the prediction of cardiotoxicity caused by cancer treatment such as doxorubicin (DOX). By using multiplex immunoassays, we identified proteins with significantly changed plasma levels in a group of breast cancer patients who were treated with DOX-based chemotherapy and produced cardiotoxicity. These proteins were associated with immune response and were identified before DOX treatment or at early doses of treatment, thus they could be potential predictive biomarkers of cardiotoxicity although further validation is required to warrant their clinical values.
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Affiliation(s)
- Li-Rong Yu
- 1 Division of Systems Biology, 12215 National Center for Toxicological Research, FDA , Jefferson, AR 72079, USA
| | - Zhijun Cao
- 1 Division of Systems Biology, 12215 National Center for Toxicological Research, FDA , Jefferson, AR 72079, USA
| | - Issam Makhoul
- 2 12215 University of Arkansas for Medical Sciences , Little Rock, AR 72205, USA
| | - Jaclyn R Daniels
- 1 Division of Systems Biology, 12215 National Center for Toxicological Research, FDA , Jefferson, AR 72079, USA
| | - Suzanne Klimberg
- 2 12215 University of Arkansas for Medical Sciences , Little Rock, AR 72205, USA
| | - Jeanne Y Wei
- 2 12215 University of Arkansas for Medical Sciences , Little Rock, AR 72205, USA
| | - Jane Pf Bai
- 3 Center for Drug Evaluation and Research, FDA, Silver Spring, MD 20903, USA
| | - Jinong Li
- 4 Center for Devices and Radiological Health, FDA, Silver Spring, MD 20903, USA
| | - Julia T Lathrop
- 5 Center for Biologics Evaluation and Research, FDA, Silver Spring, MD 20903, USA
| | - Richard D Beger
- 1 Division of Systems Biology, 12215 National Center for Toxicological Research, FDA , Jefferson, AR 72079, USA
| | - Valentina K Todorova
- 2 12215 University of Arkansas for Medical Sciences , Little Rock, AR 72205, USA
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The Positive Effects of Exercise in Chemotherapy-Related Cardiomyopathy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1000:103-129. [DOI: 10.1007/978-981-10-4304-8_8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Law W, Johnson C, Rushton M, Dent S. The Framingham risk score underestimates the risk of cardiovascular events in the HER2-positive breast cancer population. ACTA ACUST UNITED AC 2017; 24:e348-e353. [PMID: 29089804 DOI: 10.3747/co.24.3684] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Patients with breast cancer (bca) who overexpress her2 (the human epidermal growth factor receptor 2) are at risk for cardiotoxicity when treated with anthracycline-based chemotherapy and her2-targeted agents. The Framingham risk score (frs) is a validated tool that stratifies patients into high-, intermediate-, or low-risk groups and calculates their 10-year risk of developing cardiovascular disease (cvd) based on past medical history, systolic blood pressure, and measurement of serum lipids. We retrospectively analyzed patients with her2-positive bca to determine whether the frs predicts adverse cardiovascular (CV) events or cardiotoxicity in patients treated using anthracyclines or her2-targeted therapy, or both. METHODS The frs was determined for patients with bca referred to The Ottawa Hospital Cardiology-Oncology Clinic from October 2008 to August 2014. The patients were stratified into high (≥20%), intermediate (10%-20%), and low (<10%) 10-year cv risk groups. Primary outcomes included cvd-related hospitalizations and deaths, and cardiotoxicity [drop in left ventricular ejection fraction (lvef) of >10% to a lvef ≤50%]. RESULTS Of the 152 patients included in the analysis (median follow-up: 40.7 months; range: 3.5-263 months), 47 (31%) were classified as high risk; 36 (24%), as intermediate risk; and 69 (45%), as low-risk. The number of cvd-related hospitalizations and deaths was 22, for an overall prevalence of 14%, with significantly more events occurring in high-risk than in low-risk patients (odds ratio: 4.18; 95% confidence limits: 1.47, 11.89). The frs predicted a 10-year risk of any cv event of 11.2% and underestimated the actual rate of cv events in the entire cohort. High frs was not associated with cardiotoxicity (p = 0.82). CONCLUSIONS In a population of patients with her2-positive bca referred to a cardiology-oncology clinic, the frs does not accurately predict the risk of cv events or cardiotoxicity.
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Affiliation(s)
| | - C Johnson
- Division of Cardiology, Department of Medicine, and
| | | | - S Dent
- Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, ON
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38
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Early Evidence of Cardiotoxicity and Tumor Response in Patients with Sarcomas after High Cumulative Dose Doxorubicin Given as a Continuous Infusion. Sarcoma 2017; 2017:7495914. [PMID: 29081684 PMCID: PMC5634608 DOI: 10.1155/2017/7495914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/20/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite the dose-dependent response rate of sarcomas to doxorubicin, clinicians limit its cumulative dose due to cardiotoxicity. This study evaluates early evidence of cardiotoxicity in patients treated with high-dose doxorubicin given as a continuous infusion. METHODS Data was collected on patients who received 90 mg/m2 doxorubicin as a continuous infusion and 10 gm/m2 ifosfamide for up to 6 cycles as part of a phase II study. Cardiotoxicity was assessed with serial echocardiograms or multigated acquisition scans and serum brain natriuretic peptide and troponin levels. Tumor responses were determined by serial radiographic imaging per RECIST. RESULT Out of the 48 patients enrolled, no patient developed heart failure symptoms; however, 4 out of the 38 (10%) patients with serial left ventricular ejection fraction assessments developed subclinical cardiotoxicity (asymptomatic drop in LVEF ≥ 10%). Twenty-three patients received all six 72-hour cycles of doxorubicin with a mean cumulative dose of 540 mg/m2. Among these patients, 4% (n = 1) developed subclinical cardiotoxicity. In the advanced disease group (n = 39), patients with a complete or partial response received a higher mean cumulative dose than those with stable disease (p < 0.033). CONCLUSIONS Doxorubicin cardiotoxicity can be limited by administering doxorubicin as a continuous infusion, allowing higher cumulative dosing to maximize efficacy.
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Zhang CJ, Pei XL, Song FY, Guo Y, Zhang QL, Shu XH, Hsi DH, Cheng LL. Early anthracycline-induced cardiotoxicity monitored by echocardiographic Doppler parameters combined with serum hs-cTnT. Echocardiography 2017; 34:1593-1600. [PMID: 28942608 DOI: 10.1111/echo.13704] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE As growing numbers of long-term cancer survivors faced with the cardiac side effects by anthracycline treatment, it is necessary to explore the optimal monitoring method for the early detection of cardiac toxicity. METHODS We conducted a retrospective analysis of 82 consecutive patients with diffuse large B-cell lymphoma treated with chemotherapy. Echocardiographic Doppler imaging-derived Tei index and mitral annular peak systolic velocity (Sm) measured by tissue Doppler imaging TDI, serum high-sensitivity cardiac troponin T (hs-cTnT) levels, and left ventricular ejection fraction (LVEF) by multigated radionuclide angiography (MUGA) were obtained before, after 2-4, and after 6-8 chemotherapy cycles. Cardiotoxicity was defined as a relative reduction of LVEF ≥10% from the baseline or LVEF <50% as measured by MUGA. RESULTS Following chemotherapy, 24 (29.3%) patients developed detectable cardiac abnormality during the treatment. Five (6.1%) patients' cardiac function changed from normal baseline LVEF to <50% after the chemotherapy. Echocardiographic pulse wave Doppler Tei index (PW Tei index) (baseline 0.347 ± 0.115 vs 2-4 cycles 0.459 ± 0.161 vs 6-8 cycles 0.424 ± 0.139, P = .000) inversely correlated with systolic (P < .001) and diastolic dysfunction (P < .001). Serum hs-cTnT levels increased significantly following chemotherapy after 2-4 cycles of chemotherapy with anthracycline. The increase in PW Tei index of 0.095 [sensitivity, 69.2%; specificity, 64.5%; area under the curve (AUC) = 0.697; P = .005] and the Sm < 13.65 cm/s (sensitivity, 66.7%; specificity, 71%; AUC = 0.682; P = .009) combined with elevation of serum hs-cTnT level of 0.0075 ng/mL (sensitivity, 69.2%; specificity, 83.9%; AUC = 0.790; P < .001) after 2-4 chemotherapy cycles from the baseline values can reliably predict cardiotoxicity. CONCLUSIONS We demonstrated that echocardiographic PW Doppler-derived Tei index, and TDI-derived Sm, combined with serum hs-cTnT level can be obtained in outpatient settings to monitor early cardiac toxicity induced by anthracycline therapy.
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Affiliation(s)
- Chu-Jie Zhang
- Department of Echocardiography, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Li Pei
- Department of Echocardiography, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Cardiology, Kashgar Prefecture Second People's Hospital, Xinjiang, China
| | - Fei-Yan Song
- Department of Echocardiography, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ye Guo
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Qun-Ling Zhang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xian-Hong Shu
- Department of Echocardiography, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Zhongshan Hospital, Fudan University, Shanghai, China
| | - David H Hsi
- Department of Cardiology, Columbia University College of Physicians & Surgeons, Stamford Hospital, Stamford, CT, USA
| | - Lei-Lei Cheng
- Department of Echocardiography, Shanghai Institute of Cardiovascular Diseases, Shanghai Institute of Medical Imaging, Zhongshan Hospital, Fudan University, Shanghai, China
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Chen-Scarabelli C, McRee C, Leesar MA, Hage FG, Scarabelli TM. Comprehensive review on cardio-oncology: Role of multimodality imaging. J Nucl Cardiol 2017; 24:906-935. [PMID: 27225513 DOI: 10.1007/s12350-016-0535-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
Abstract
Cancer and cardiovascular disease are the two leading causes of mortality worldwide. Evolving oncologic therapy, including the use of newer targeted agents, has led to an improvement in survival from childhood- and adult-onset cancers. Consequently, there has been a growing realization of cardiotoxic complications related to cancer therapy, with some complications manifesting over months to decades after completion of cancer treatment. This paper reviews cancer therapeutics-related cardiovascular toxicity and its manifestations, multimodality imaging techniques for surveillance and detection of this complication, and the current state of knowledge in this emerging field.
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Affiliation(s)
- Carol Chen-Scarabelli
- Birmingham Veterans Affairs Medical Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chad McRee
- Division of Cardiovascular Disease, University of Alabama at Birmingham, 1530 3rd Avenue, South Tinsley Harrison Tower, Birmingham, Alabama, 35294-0006, USA
| | - Massoud A Leesar
- Birmingham Veterans Affairs Medical Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Cardiovascular Disease, University of Alabama at Birmingham, 1530 3rd Avenue, South Tinsley Harrison Tower, Birmingham, Alabama, 35294-0006, USA
| | - Fadi G Hage
- Birmingham Veterans Affairs Medical Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Cardiovascular Disease, University of Alabama at Birmingham, 1530 3rd Avenue, South Tinsley Harrison Tower, Birmingham, Alabama, 35294-0006, USA
| | - Tiziano M Scarabelli
- Birmingham Veterans Affairs Medical Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.
- Division of Cardiovascular Disease, University of Alabama at Birmingham, 1530 3rd Avenue, South Tinsley Harrison Tower, Birmingham, Alabama, 35294-0006, USA.
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Abstract
OPINION STATEMENT Recent advances in cancer treatment and research have greatly improved survival rates for patients with cancer. However, many of these cancer survivors are developing cardiac disease-most commonly heart failure as a result of this treatment. Certain chemotherapeutic agents, including anthracyclines and trastuzumab, have been linked to cardiotoxicity-induced cardiomyopathy in cancer patients. It has been reported as early as during infusion and as late as several years following treatment. Radiation therapy, particularly to the left breast, has also been linked to cardiac disease. The responsibility of cardiac monitoring has traditionally fallen on oncologists using assessment of LVEF through multigated acquisition (MUGA) scans or echocardiograms. The "formal" definition of cardiotoxicity, as a 5 to 10% decrease in LVEF from its baseline, even though not validated, is currently used by clinicians to alter treatment, but it has been recently challenged, as a possible irreversible late stage of a myocardial insult. Furthermore, it falls into the interobserver variability range of echocardiography. The growing field of medicine called cardio-oncology is based on emerging research that has shown that more advanced imaging modalities can help detect cardiotoxicity early, allowing the patient to receive treatment and avoid developing heart failure from cancer treatment. While traditional imaging still has its place in cardiac monitoring, cardiac magnetic resonance imaging is the most accurate and detailed imaging modality available to assess cardiotoxicity. Our own pilot cardiac MRI study suggests that a normal left ventricular remodeling to chemotherapy, when patients have not developed heart failure symptoms, could occur over time. Perhaps, knowing a baseline normal response could help us to define a more accurate definition of cardiotoxicity by CMR. Here, we discuss various imaging modalities and emerging techniques that can assist in detecting early signs of cardiotoxicity and thus reduce the incidence of cardiac disease in cancer survivors.
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Affiliation(s)
- Erick Avelar
- Division of Cardiology, Oconee Heart and Vascular Center, Augusta University/University of Georgia Medical Partnership, 2470 Daniells Bridge Road, Bldg. 200, Ste. 251, Athens, GA, 30606, USA.
| | - Caitlin R Strickland
- Oconee Heart and Vascular Center, The Exchange, 2470 Daniells Bridge Road, Bldg. 200, Suite 251, Athens, GA, 30606, USA
| | - Guido Rosito
- Division of Cardiology, UFCSPA (Universidade Federal de Ciências da Saúde de Porto Alegre), Rua Itororó 160/1305, POA, RS, 90110290, Brazil
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Bian SX, Korah MP, Whitaker TR, Ji L, Groshen S, Chung E. No Acute Changes in LVEF Observed With Concurrent Trastuzumab and Breast Radiation With Low Heart Doses. Clin Breast Cancer 2017; 17:510-515. [PMID: 28412326 DOI: 10.1016/j.clbc.2017.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 02/28/2017] [Accepted: 03/15/2017] [Indexed: 12/24/2022]
Abstract
INTRODUCTION/BACKGROUND Treatment for HER2-postitive breast cancer often includes trastuzumab, breast/chest wall (CW) radiation (RT), and anthracyclines, all of which have cardiac toxicity. We aimed to evaluate the relationship between heart dose and acute left ventricular ejection fraction (LVEF) changes in patients who received concurrent trastuzumab and breast/CW RT with and without anthracycline use. PATIENTS AND METHODS We retrospectively reviewed all nonmetastatic breast cancer patients from 2008 to 2015 who received concurrent trastuzumab and breast/CW RT. Baseline LVEF was compared with the LVEF closest to treatment completion as well as with the lowest post-treatment LVEF. LVEF changes were correlated with laterality, heart dosimetric parameters, and doxorubicin use. RESULTS Eighty-eight patients were included in our analysis. The median follow-up was 45 months. Forty-one patients were right-sided and 47 left-sided. Thirty-one patients received doxorubicin, 16 right-sided and 15 left-sided. Mean heart dose was 1.10 Gy and 3.63 Gy for right- and left-sided patients, respectively (P < .001). In the entire cohort, a significant LVEF decrease of 3.0% was observed pre- and post-treatment. There was a significant effect of doxorubicin (P = .013) and a nonsignificant effect of RT laterality (P = .088) on LVEF change. The test of interaction between doxorubicin and laterality was not significant (P = .90). No significant association was found between LVEF change and heart dosimetric parameters, including percent volume of heart receiving 5 Gy (V5), 10 Gy (V10), 20 Gy (V20), and 45 Gy (V45), and maximum dose. Similar results were found when baseline LVEF was compared with the lowest post-treatment LVEF. CONCLUSION With cardiac doses < 4 Gy, declines in LVEF were not related to tumor laterality or heart dosimetric parameters. Statistically significant LVEF decreases were mainly attributed to doxorubicin.
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Affiliation(s)
- Shelly X Bian
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA.
| | - Mariam P Korah
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Taylor R Whitaker
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Lingyun Ji
- Department of Biostatistics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Susan Groshen
- Department of Biostatistics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Eugene Chung
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA
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Zito C, Longobardo L, Cadeddu C, Monte I, Novo G, Dell'Oglio S, Pepe A, Madonna R, Tocchetti CG, Mele D. Cardiovascular imaging in the diagnosis and monitoring of cardiotoxicity: role of echocardiography. J Cardiovasc Med (Hagerstown) 2017; 17 Suppl 1 Special issue on Cardiotoxicity from Antiblastic Drugs and Cardioprotection:e35-e44. [PMID: 27755241 DOI: 10.2459/jcm.0000000000000374] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The evaluation by cardiovascular imaging of chemotherapy patients became a central topic in the last several years. The use of drugs for the treatment of cancers increased, and new molecules and protocols were developed to improve outcomes in these patients. Although, these novel approaches also produced a progressive increase in side effects, particularly myocardial dysfunction. Imaging of the heart was highly accurate in the early diagnosis of cancer therapeutics related-cardiac dysfunction. Echocardiography is the first-line method to assess ventricular function alterations, and it is required to satisfy the need for an early, easy and accurate diagnosis to stratify the risk of heart failure and manage treatments. A careful monitoring of cardiac function during the course of therapy should prevent the onset of severe heart impairment. This review provides an overview of the most important findings of the role of echocardiography in the management of chemotherapy-treated patients to create a clear and complete description of the efficacy of conventional measurements, the importance of comprehensive heart evaluations, the additional role of new echocardiographic techniques, the utility of integrated studies using other imaging tools and the positions of the most important international societies on this topic.
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Affiliation(s)
- Concetta Zito
- aDepartment of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Messina bDepartment of Medical Sciences 'Mario Aresu', University of Cagliari, Cagliari cDepartment of General Surgery and Medical-Surgery Specialties, Section of Cardiology, University of Catania, Catania dChair and Division of Cardiology, University of Palermo, Palermo eU.O.C. Magnetic Resonance Imaging, Fondazione G. Monasterio C.N.R., Pisa fInstitute of Cardiology, Center of Excellence on Aging, 'G. d'Annunzio' University, Chieti gDipartimento di Scienze Mediche Traslazionali, Universita' degli Studi di Napoli Federico II hCardiology Unit, University Hospital of Ferrara, Ferrara, Italy
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Bredahl EC, Hydock DS. Creatine Supplementation and Doxorubicin-Induced Skeletal Muscle Dysfunction: An Ex Vivo Investigation. Nutr Cancer 2017; 69:607-615. [PMID: 28323480 DOI: 10.1080/01635581.2017.1295089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Supplementing the diet with creatine (Cr) to manage chemotherapy-induced skeletal muscle weakness and fatigue has potential, but little has been done exploring it as an intervention. This study examined the effects of Cr on skeletal muscle dysfunction induced by the chemotherapy drug doxorubicin (Dox). Soleus and extensor digitorum longus (EDL) from male Sprague-Dawley rats maintained in an organ bath were incubated in Krebs-Henseleit (KH) buffer with or without creatine monohydrate (25 mM) for 30 min. Skeletal muscle was then incubated in KH buffer with or without Dox (24 μM) for an additional 30 min. Baths were then refreshed with KH buffer, and a 100-s fatigue protocol was administered. At baseline (0 s time point), no significant differences in force production were observed in the slow, type I soleus, but the Dox-treated soleus fatigued quicker than the non-Dox-treated soleus; however, pretreatment with Cr extended the time to fatigue in the Dox-treated soleus. In the fast, type II EDL, Dox treatment decreased force production at baseline and increased fatigue, and Cr treatment prior to Dox attenuated this dysfunction. Creatine pretreatment mitigated Dox-induced skeletal muscle dysfunction ex vivo suggesting that Cr may play a role in managing Dox-induced skeletal muscle side effects.
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Affiliation(s)
- Eric C Bredahl
- a Department of Exercise Science and Pre-Health Professions , Creighton University , Omaha , Nebraska , USA
| | - David S Hydock
- b School of Sport and Exercise Science, University of Northern Colorado , Greeley , Colorado , USA.,c The University of Northern Colorado Cancer Rehabilitation Institute, University of Northern Colorado , Greeley , Colorado , USA
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Laursen AH, Thune JJ, Hutchings M, Hasbak P, Kjaer A, Elming MB, Ripa RS. 123
I-MIBG imaging for detection of anthracycline-induced cardiomyopathy. Clin Physiol Funct Imaging 2017; 38:176-185. [DOI: 10.1111/cpf.12419] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 01/19/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Adam H. Laursen
- Department of Haematology; Rigshospitalet; Copenhagen Denmark
| | | | | | - Philip Hasbak
- Department of Clinical Physiology; Nuclear Medicine & PET and Cluster for Molecular Imaging; Rigshospitalet and University of Copenhagen; Copenhagen Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology; Nuclear Medicine & PET and Cluster for Molecular Imaging; Rigshospitalet and University of Copenhagen; Copenhagen Denmark
| | - Marie B. Elming
- Department of Cardiology; Rigshospitalet; Copenhagen Denmark
| | - Rasmus S. Ripa
- Department of Clinical Physiology; Nuclear Medicine & PET and Cluster for Molecular Imaging; Rigshospitalet and University of Copenhagen; Copenhagen Denmark
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46
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Jannazzo A, Hoffman J, Lutz M. Monitoring of Anthracycline-Induced Cardiotoxicity. Ann Pharmacother 2016; 42:99-104. [PMID: 18094345 DOI: 10.1345/aph.1k359] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To review the literature regarding the appropriate monitoring for anthracycline-induced cardiotoxicity. Data Sources: A MEDLINE search of the literature was performed (1966–August 2007). Search terms included anthracycline, cardiotoxicity, and monitoring. Additional references were identified through bibliographic reviews. Data Synthesis: Anthracycline medications are effective in the treatment of many malignancies but their use is limited by their associated cardiotoxicity. The focus of anthracycline-induced cardiotoxicity prevention has been on monitoring cardiac function during treatment; however, a consensus on the most appropriate way to monitor patients is not available. Most guidelines lack specific details on the appropriate methods of cardiac evaluation and schedule. One guideline that does provide specific recommendations on both the method of evaluation and schedule has been criticized for being too restrictive, costly, and tacking in evidentiary support. The literature is insufficient in evaluation of the predictive value of cardiac function monitoring by echocardiography or radionuclide angiography during anthracycline therapy and the future development of cardiotoxicity, the necessity of baseline cardiac function monitoring, the optimal follow-up cardiac evaluation schedule, and the addition of risk stratification to monitoring schemes. Conclusions: Although guidelines are Inadequate to predict and prevent anthracycline-induced cardiotoxicity, until further research is available, following one of the existing guidelines to monitor for this adverse effect is a practical solution.
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Affiliation(s)
- Abigail Jannazzo
- Pharmacy Practice Resident, Department of Pharmaceutical Services, William Beaumont Hospital, Royal Oak, Ml; now, Oncology Specialty Resident, Evanston Northwestern Healthcare, Evanston, IL
| | - Janet Hoffman
- Drug Information Specialist, Department of Pharmaceutical Services, William Beaumont Hospital
| | - Mark Lutz
- Drug Information Specialist, Department of Pharmaceutical Services, William Beaumont Hospital
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Murbraech K, Holte E, Broch K, Smeland KB, Holte H, Rösner A, Lund MB, Dalen H, Kiserud C, Aakhus S. Impaired Right Ventricular Function in Long-Term Lymphoma Survivors. J Am Soc Echocardiogr 2016; 29:528-36. [DOI: 10.1016/j.echo.2016.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Indexed: 01/08/2023]
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Yokoyama C, Aoyama T, Ido T, Kakino A, Shiraki T, Tanaka T, Nishigaki K, Hasegawa A, Fujita Y, Sawamura T, Minatoguchi S. Deletion of LOX-1 Protects against Heart Failure Induced by Doxorubicin. PLoS One 2016; 11:e0154994. [PMID: 27195769 PMCID: PMC4873018 DOI: 10.1371/journal.pone.0154994] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 04/22/2016] [Indexed: 01/28/2023] Open
Abstract
Oxidative stress is one of the major factors in doxorubicin (DOX)-induced cardiomyopathy. Lectin-like oxidized low-density lipoprotein (oxLDL) receptor-1 (LOX-1) plays an important role to regulate cardiac remodeling and oxidative stress after ischemia-reperfusion. Therefore, we examined whether or not LOX-1 contributes to the pathogenesis of DOX-induced cardiomyopathy. Cardiomyopathy was induced by a single intraperitoneal injection of DOX into wild-type (WT) mice and LOX-1 knockout (KO) mice. Echocardiography and catheter-based hemodynamic assessment apparently revealed preserved left ventricular (LV) fractional shortening (FS) and cavity size of LOX-1 KO mice compared with those of WT mice after DOX administration. Less production of tumor necrosis factor alpha (TNF-α) and interleukin-1 beta (IL-1ß) was observed in LOX-1 KO mice than WT mice after DOX administration. Western blotting analysis also showed lower activation of nuclear factor κB (NF-κB) and p38 mitogen-activated protein kinase (MAPK) in LOX-1 KO mice treated with DOX than WT mice treated with DOX. In fact, NF-κB-dependent gene expressions of LOX-1 and vascular cell adhesion molecule-1 (VCAM-1) were suppressed in LOX-1 KO mice treated with DOX compared with WT mice treated with DOX. Therefore, histological analyses showed attenuation of leukocyte infiltration and cardiac fibrosis in LOX-1 KO mice compared with WT mice. Meanwhile, extracellular signal-regulated kinase MAPK (ERK) inactivation and decreased expression of sarcomeric proteins and related transcription factor GATA-4 in WT mice treated with DOX administration were not seen in LOX-1 KO mice treated with DOX administration and WT and LOX-1 KO mice treated with vehicle. Decreased expression of sarcometric proteins resulted in smaller diameters of cardiomyocytes in WT mice than in LOX-1 KO mice after DOX treatment. The expression of LOX-1 in cardiomyocytes was much more abundant than that in endothelial cells, fibroblasts and inflammatory cells. Endothelial cells, fibroblasts and inflammatory cells treated with DOX showed no elevated LOX-1 expression compared with those treated with vehicle. However, cardiomyocytes treated with DOX showed much more expression of LOX-1 than those treated with vehicle. Immunohistochemistry study also showed that LOX-1 expression was strongly elevated in cardiomyocytes in the heart tissue of mice treated with DOX in vivo. We conclude that LOX-1 in cardiomyocytes plays the most important roles in the pathology of DOX-induced cardiomyopathy. LOX-1 deletion altered the LOX-1-related signaling pathway, which led to improvements in cardiac function, myocardial inflammation, fibrosis and degenerative changes after DOX treatment.
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Affiliation(s)
- Chiharu Yokoyama
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takuma Aoyama
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
- Cardiovascular Center, Kizawa Memorial Hospital, Minokamo, Japan
- * E-mail:
| | - Takahiro Ido
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
- Cardiovascular Center, Kizawa Memorial Hospital, Minokamo, Japan
| | - Akemi Kakino
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Osaka, Japan
- Department of Physiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takeru Shiraki
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Toshiki Tanaka
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazuhiko Nishigaki
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Aiko Hasegawa
- Department of Physiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiko Fujita
- Department of Physiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tatsuya Sawamura
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Osaka, Japan
- Department of Physiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shinya Minatoguchi
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
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van Dalen EC, van der Pal HJH, Kremer LCM. Different dosage schedules for reducing cardiotoxicity in people with cancer receiving anthracycline chemotherapy. Cochrane Database Syst Rev 2016; 3:CD005008. [PMID: 26938118 PMCID: PMC6457744 DOI: 10.1002/14651858.cd005008.pub4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND This review update has been managed by both the Childhood Cancer and Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Groups.The use of anthracycline chemotherapy is limited by the occurrence of cardiotoxicity. To prevent this cardiotoxicity, different anthracycline dosage schedules have been studied. OBJECTIVES To determine the occurrence of cardiotoxicity with the use of different anthracycline dosage schedules (that is peak doses and infusion durations) in people with cancer. SEARCH METHODS We searched the databases of the Cochrane Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 11, 2015), MEDLINE (1966 to December 2015), and EMBASE (1980 to December 2015). We also searched reference lists of relevant articles, conference proceedings, experts in the field, and ongoing trials databases. SELECTION CRITERIA Randomised controlled trials (RCTs) in which different anthracycline dosage schedules were compared in people with cancer (children and adults). DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection, the 'Risk of bias' assessment, and data extraction. We performed analyses according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We identified 11 studies: 7 evaluated different infusion durations (803 participants), and 4 evaluated different peak doses (5280 participants). Seven studies were RCTs addressing different anthracycline infusion durations; we identified long-term follow-up data for one of the trials in this update. The meta-analysis showed a statistically significant lower rate of clinical heart failure with an infusion duration of six hours or longer as compared to a shorter infusion duration (risk ratio (RR) 0.27; 95% confidence interval 0.09 to 0.81; 5 studies; 557 participants). The majority of participants included in these studies were adults with different solid tumours. For different anthracycline peak doses, we identified two RCTs addressing a doxorubicin peak dose of less than 60 mg/m(2) versus 60 mg/m(2) or more, one RCT addressing a liposomal doxorubicin peak dose of 25 mg/m(2) versus 50 mg/m(2), and one RCT addressing an epirubicin peak dose of 83 mg/m(2) versus 110 mg/m(2). A significant difference in the occurrence of clinical heart failure was identified in none of the studies. The participants included in these studies were adults with different solid tumours. High or unclear 'Risk of bias' issues were present in all studies. AUTHORS' CONCLUSIONS An anthracycline infusion duration of six hours or longer reduces the risk of clinical heart failure, and it seems to reduce the risk of subclinical cardiac damage. Since there is only a small amount of data for children and data obtained in adults cannot be extrapolated to children, different anthracycline infusion durations should be evaluated further in children.We identified no significant difference in the occurrence of clinical heart failure in participants treated with a doxorubicin peak dose of less than 60 mg/m(2) or 60 mg/m(2) or more. Only one RCT was available for the other identified peak doses, so we can make no definitive conclusions about the occurrence of cardiotoxicity. More high-quality research is needed, both in children and adults and in leukaemias and solid tumours.
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Affiliation(s)
- Elvira C van Dalen
- Department of Paediatric Oncology, Emma Children's Hospital/Academic Medical Center, PO Box 22660 (room TKsO-247), Amsterdam, Netherlands, 1100 DD
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Rosa GM, Gigli L, Tagliasacchi MI, Di Iorio C, Carbone F, Nencioni A, Montecucco F, Brunelli C. Update on cardiotoxicity of anti-cancer treatments. Eur J Clin Invest 2016; 46:264-84. [PMID: 26728634 DOI: 10.1111/eci.12589] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 12/30/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Anti-cancer treatments markedly improved the prognosis of patients, but unfortunately might be hampered by cardiotoxicity. Both symptomatic and asymptomatic clinical forms of heart failure have been reported, which may be reversible or irreversible. The aim of this review is to provide an overview of the antineoplastic agents associated with cardiac toxicity and of the available diagnostic techniques. METHODS AND METHODS This narrative review is based on material from MEDLINE and PUBMED up to November 2015. We looked at the terms antineoplastic drugs and cardiac toxicity in combination with echocardiography, troponins, cardiac magnetic resonance, and positron emission tomography. RESULTS Anthracyclines, monoclonal antibodies, fluoropyrimidines, taxanes, alkylating agents, vinka alkaloids were reported to induce different clinical manifestations of cardioxicity. Chest radiotherapy is also associated with various forms of cardiac damage, which are indistinguishable from those found in patients with heart disease of other aetiologies and that may even appear several years after administration. Among diagnostic techniques, echocardiography is a noninvasive, cost-effective, and widely available imaging tool. Nuclear imaging and cardiac magnetic resonance may be used but are not so widely available and are more difficult to perform. Finally, some biomarkers, such as troponins, may be used to evaluate cardiac damage, but establishing the optimal timing of troponin assessment remains unclear and defining the cut-off point for positivity is still an important goal. CONCLUSIONS Cardiotoxicity of anti-cancer treatments is associated with development of heart failure. Novel diagnostic tools might be relevant to early recognize irreversible forms cardiac diseases.
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Affiliation(s)
- Gian Marco Rosa
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Lorenzo Gigli
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Maria Isabella Tagliasacchi
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Cecilia Di Iorio
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Federico Carbone
- Division of Cardiology, Foundation for Medical Researches, Department of Medical Specialties, Geneva University, Geneva, Switzerland
| | - Alessio Nencioni
- Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Istituto Nazionale per la Ricerca Sul Cancro, Genoa, Italy
| | - Fabrizio Montecucco
- Division of Cardiology, Foundation for Medical Researches, Department of Medical Specialties, Geneva University, Geneva, Switzerland.,First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino-IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Claudio Brunelli
- Division of Cardiology, Department of Internal Medicine, University of Genoa - IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
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