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Summey R, Aliani R, McAlarnen LA, Sequeira N, Shaik T, Uyar D, Brown SA. Syndromes of Concurrent Hypertension, Diastolic Dysfunction, and Pulmonary or Peripheral Edema in Cardio-Oncology: Case Studies, Literature Review, and New Classification System. Curr Treat Options Oncol 2023; 24:1917-1934. [PMID: 38091185 DOI: 10.1007/s11864-023-01141-9] [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] [Accepted: 10/10/2023] [Indexed: 01/11/2024]
Abstract
OPINION STATEMENT Individuals who have ever been diagnosed with cancer are at increased risk for cardiovascular conditions during and after cancer treatment. Especially during cancer treatment, cardiovascular conditions can manifest in many ways, including peripheral or pulmonary edema. Edema can indicate volume overload affecting the heart even without other unequivocal evidence of apparent diastolic or systolic left ventricular dysfunction, particularly at rest. We propose a novel algorithm to streamline the diagnostic evaluation and cardiovascular classification for cancer patients with edema. We initially advise prompt evaluation with a chest X-ray and echocardiogram. We then suggest classification into one of five categories based on the timing of presentation of edema relative to cancer treatment, as well as echocardiography results and the presence or absence of hypertension or lymphatic causes of edema. This classification tool can then be utilized to guide further cardiovascular management suggestions. These concurrent syndromes presenting as edema may indicate the development or aggravation of undiagnosed diastolic dysfunction with or without hypertension, even if transiently present only while on cancer treatment.
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Affiliation(s)
- Rebekah Summey
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Rana Aliani
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lindsey A McAlarnen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Nicole Sequeira
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Tahseen Shaik
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Denise Uyar
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Sherry-Ann Brown
- Cardio-oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
- Preventive Cardio-Oncology LLC, Miami, FL, USA.
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Management of Peripheral Edema in Patients with MET Exon 14-Mutated Non-small Cell Lung Cancer Treated with Small Molecule MET Inhibitors. Target Oncol 2022; 17:597-604. [PMID: 36087188 PMCID: PMC9512730 DOI: 10.1007/s11523-022-00912-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/03/2022]
Abstract
Small molecule mesenchymal-epithelial transition (MET) inhibitors, such as crizotinib, capmatinib, and tepotinib, are treatment options for metastatic non-small cell lung cancer (NSCLC) in adult patients whose tumors have a mutation that leads to MET exon 14 skipping. In clinical trials, these MET inhibitors were associated with a high incidence of peripheral edema, although this was generally mild-to-moderate in severity. There is limited information about the mechanism involved in MET inhibitor-induced peripheral edema. Perturbation of hepatocyte growth factor (HGF)/MET signaling may disrupt the permeability balance in the vascular endothelium and thus promote edema development. Another potential mechanism is through effects on renal function, although this is unlikely to be the primary mechanism. Because edema is common in cancer patients and may not necessarily be caused by the cancer treatment, or other conditions that have similar symptoms to peripheral edema, a thorough assessment is required to ascertain the underlying cause. Before starting MET-inhibitor therapy, patients should be educated about the possibility of developing peripheral edema. Patient limb volume should be measured before initiating treatment, to aid assessment if symptoms develop. Since the exact mechanism of MET inhibitor-induced edema is unknown, management is empiric, with common approaches including compression stockings, specific exercises, massage, limb elevation, and/or diuretic treatment. Although not usually required, discontinuation of MET inhibitor treatment generally resolves peripheral edema. Early diagnosis and management, as well as patient information and education, are vital to decrease the clinical burden associated with edema, and to reinforce capmatinib treatment adherence.
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Pateva I, Greene AK, Snyder KM. How we approach lymphedema in the pediatric population. Pediatr Blood Cancer 2022; 69 Suppl 3:e29908. [PMID: 36070213 DOI: 10.1002/pbc.29908] [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: 07/19/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 11/05/2022]
Abstract
Lymphedema in children is rare; however, it is usually a progressive and chronic condition. Accurate diagnosis of lymphedema in the pediatric population often takes several months and sometimes is delayed for years. Lymphedema can be isolated or associated with genetic syndromes, thus it is very important to identify the correct diagnosis, to select carefully which patients to refer for genetic testing, and to initiate appropriate treatment in a timely fashion. In this article, we review key information about diagnosis of lymphedema, associated conditions and syndromes, and current treatment modalities.
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Affiliation(s)
- Irina Pateva
- Pediatric Hematology/Oncology, Rainbow Babies and Children's Hospital, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kristen M Snyder
- Comprehensive Vascular Anomalies Program, Solid Tumor Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Pateva I, Greene AK, Snyder KM. How we approach lymphedema in the pediatric population. Pediatr Blood Cancer 2022; 69:e29611. [PMID: 35404535 DOI: 10.1002/pbc.29611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/14/2022] [Accepted: 01/25/2022] [Indexed: 11/10/2022]
Abstract
Lymphedema in children is rare; however, it is usually a progressive and chronic condition. Accurate diagnosis of lymphedema in the pediatric population often takes several months and sometimes is delayed for years. Lymphedema can be isolated or associated with genetic syndromes, thus it is very important to identify the correct diagnosis, to select carefully which patients to refer for genetic testing, and to initiate appropriate treatment in a timely fashion. In this article, we review key information about diagnosis of lymphedema, associated conditions and syndromes, and current treatment modalities.
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Affiliation(s)
- Irina Pateva
- Pediatric Hematology/Oncology, Rainbow Babies and Children's Hospital, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kristen M Snyder
- Comprehensive Vascular Anomalies Program, Solid Tumor Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Dávila Osorio VL, Vicente MA, Baselga E, Salvador H, Cruz O, Prat C. Adverse cutaneous effects of mitogen-activated protein kinase inhibitors in children. Pediatr Dermatol 2021; 38:420-423. [PMID: 33368596 DOI: 10.1111/pde.14354] [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] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mitogen-activated protein kinase inhibitors (MEKi) are currently used for the treatment of central nervous system tumors in children and have shown promising results. Cutaneous adverse effects are among the most common toxicities described in adults, but few studies exist in pediatric patients. OBJECTIVE We aimed to describe the cutaneous adverse effects associated with MEKi in pediatric patients. METHODS A retrospective study was carried out at our pediatric hospital in Barcelona, Spain, in patients undergoing treatment with MEKi. RESULTS Sixty-one children between 1 and 18 years of age were included. All patients developed cutaneous toxicity. Eczema, hair abnormalities, oral aphthae, and paronychia were among the most common cutaneous side effects. CONCLUSIONS Recognizing skin toxicity in pediatric patients under treatment with MEKi is essential to establishing appropriate education and therapy, thereby improving treatment tolerability and minimizing avoidable interruptions in treatment.
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Affiliation(s)
| | | | - Eulalia Baselga
- Department of Dermatology Hospital Sant Joan de Deu, Barcelona, Spain
| | - Hector Salvador
- Department of Oncology Hospital Sant Joan de Deu, Barcelona, Spain
| | - Ofelia Cruz
- Department of Oncology Hospital Sant Joan de Deu, Barcelona, Spain
| | - Carolina Prat
- Department of Dermatology Hospital Sant Joan de Deu, Barcelona, Spain
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Baldo F, Magnolato A, Barbi E, Bruno I. Selumetinib side effects in children treated for plexiform neurofibromas: first case reports of peripheral edema and hair color change. BMC Pediatr 2021; 21:67. [PMID: 33549085 PMCID: PMC7866429 DOI: 10.1186/s12887-021-02530-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Plexiform neurofibromas (PNs) are congenital tumors that affect around 50 % of the subjects with neurofibromatosis type 1. Despite being histologically benign, PNs can grow rapidly, especially in the pediatric age, and cause severe morbidities. In the past, various therapeutic approaches have been proposed to treat these masses, none of which obtained valuable results. Selumetinib, an inhibitor of mitogen-activated protein kinase (MEK) 1 and 2, has been the first molecule to demonstrate the ability of tackling the growth of PNs. The drug's most common side effects, which usually are mild or moderate, include gastrointestinal symptoms (diarrhea, abdominal pain), dermatologic manifestations (maculo-papular and acneiform rash, paronychia, mucositis), and various laboratory test abnormalities (elevation of creatine kinase and aminotransferase). CASES PRESENTATION We report two previously undescribed adverse events in pediatric patients: peripheral edema and hair color change. The first case of peripheral edema occurred in a 7-year-old boy affected by a severe form of NF1, after two years of treatment with selumetinib at the standard dose (25 mg/m2twice a day). The edema involved the right leg, and the patient did not complain of pain. The second case of peripheral edema occurred in a 12-year-old girl after six months of therapy with selumetinib at the standard dose, involving her lower left leg. The patient initially complained of pain in that area, but it gradually and spontaneously resolved. In both patients, all the radiological exams, including lymphoscintigraphy, pelvic and abdominal ultrasound, and doppler ultrasound of the affected limb, as well as blood tests, revealed no abnormalities. Hair color change appeared in a 4-year-old boy after six months of therapy at the standard dose. The boy's hair, whose natural color was dark blonde, became lighter in some areas. Despite the appearance of these side effects, all the patients and their families decided to continue the treatment with selumetinib, in considerations of its clinical benefits. CONCLUSIONS Since the use of selumetinib to treat plexiform neurofibromas is increasing in the pediatric population, clinicians should be aware of its side effects, so to decide whether continuing the treatment, reducing the dose or even interrupting it, when appropriate.
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Affiliation(s)
| | - Andrea Magnolato
- Department of Pediatrics, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- University of Trieste, Trieste, Italy.,Department of Pediatrics, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - Irene Bruno
- Department of Pediatrics, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
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Cardiovascular safety of rapidly accelerated fibrosarcoma B-type and/or mitogen-activated extracellular signal-regulated kinase inhibitors: A mixed approach combining a meta-analysis and a pharmacovigilance disproportionality analysis. Arch Cardiovasc Dis 2020; 113:420-432. [DOI: 10.1016/j.acvd.2020.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/10/2020] [Accepted: 03/09/2020] [Indexed: 12/11/2022]
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Heinzerling L, Eigentler TK, Fluck M, Hassel JC, Heller-Schenck D, Leipe J, Pauschinger M, Vogel A, Zimmer L, Gutzmer R. Tolerability of BRAF/MEK inhibitor combinations: adverse event evaluation and management. ESMO Open 2019; 4:e000491. [PMID: 31231568 PMCID: PMC6555610 DOI: 10.1136/esmoopen-2019-000491] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/06/2019] [Accepted: 03/31/2019] [Indexed: 12/11/2022] Open
Abstract
The inhibition of the mitogen-activated protein kinases signalling pathway through combined use of BRAF and MEK inhibitors (BRAFi+MEKi) represents an established therapeutic option in patients with BRAF-mutated, advanced melanoma. These efficient therapies are well tolerated with mostly moderate and reversible side effects and a discontinuation rate due to adverse events of 11.5%-15.7%. Median duration of therapy ranges between 8.8 and 11.7 months. Based on data from confirmatory trials, safety profiles of three BRAFi+MEKi combinations were reviewed, that is, dabrafenib plus trametinib, vemurafenib plus cobimetinib and encorafenib plus binimetinib. Many adverse events are class effects, such as cutaneous, gastrointestinal, ocular, cardiac and musculoskeletal events; some adverse events are substance associated. Fever (dabrafenib) and photosensitivity (vemurafenib) are the most common and clinically prominent examples. Other adverse events are less frequent and the association to one substance is less strong such as anaemia, facial paresis (encorafenib), neutropenia (dabrafenib), skin rash, QTc prolongation and increased liver function tests (vemurafenib). This narrative review provides recommendations for monitoring, adverse event evaluation and management focusing on the clinically relevant side effects of the three regimens.
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Affiliation(s)
- Lucie Heinzerling
- Department of Dermatology, University of Erlangen, Erlangen, Germany
| | - Thomas K Eigentler
- Department of Dermatology, Center for Dermatooncology, University Medical Center Tübingen, Tübingen, Germany
| | - Michael Fluck
- Department of Internal Medicine, Fachklinik Hornheide, Münster, Germany
| | - Jessica C Hassel
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Jan Leipe
- Division of Rheumatology and Clinical Immunology, Medizinische Klinik und Poliklinik IV, University of Munich, Munich, Germany
| | - Matthias Pauschinger
- Department of Cardiology, Klinikum Nürnberg Süd, Paracelsus Medical University Nürnberg, Nuremberg, Germany
| | - Arndt Vogel
- Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Lisa Zimmer
- Department of Dermatology, University Hospital, University Essen-Duisburg, Essen, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Ralf Gutzmer
- Department of Dermatology, Skin Cancer Center Hannover, Hannover Medical School, Hannover, Germany
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Lee J, Lim B, Pearson T, Choi K, Fuson JA, Bartholomeusz C, Paradiso LJ, Myers T, Tripathy D, Ueno NT. Anti-tumor and anti-metastasis efficacy of E6201, a MEK1 inhibitor, in preclinical models of triple-negative breast cancer. Breast Cancer Res Treat 2019; 175:339-351. [PMID: 30826934 DOI: 10.1007/s10549-019-05166-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/09/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE Triple-negative breast cancer (TNBC) lacks the receptor targets estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2, and thus, it does not respond to receptor-targeted treatments. TNBC has higher recurrence, metastasis, and mortality rates than other subtypes of breast cancer. Mounting data suggest that the MAPK (also known as RAS-RAF-MEK-ERK) pathway is an important therapeutic target in TNBC. METHODS To evaluate anti-tumor and anti-metastasis efficacy of E6201, we used cell proliferation assay, soft agar assay, cell cycle assay, Annexin V staining assay, immunoblotting analysis, immunohistochemistry, migration assay, invasion assay, mammary fat pad xenograft, and experimental and spontaneous metastasis xenograft models. We also evaluated the anti-tumor efficacy of E6201 plus CDK4/6 inhibitor, mTOR inhibitor, or ATR inhibitor. RESULTS E6201 inhibited TNBC cell colony formation, migration, and invasion in a dose-dependent manner. E6201 induced G1 cell cycle arrest and apoptosis. E6201 inhibited TNBC xenograft growth and inhibited TNBC lung metastasis and improved mouse survival in experimental metastasis and spontaneous metastasis assays. Immunohistochemical staining demonstrated that E6201 decreased the metastatic burden in the lung and decreased phosphorylated ERK expression in a dose-dependent manner. Combination of E6201 with CDK4/6 inhibitor or mTOR inhibitor enhanced E6201's in vitro anti-tumor efficacy. CONCLUSION These results indicate that E6201 exhibits anti-tumor efficacy against TNBC in vitro and anti-metastasis efficacy against TNBC in vivo. These results provide a rationale for further clinical development of E6201 as a MAPK-pathway-targeted therapy for TNBC.
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Affiliation(s)
- Jangsoon Lee
- Section of Translational Breast Cancer Research, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1354, 1515 Holcombe Boulevard, Houston, TX, 77030-4009, USA
| | - Bora Lim
- Section of Translational Breast Cancer Research, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1354, 1515 Holcombe Boulevard, Houston, TX, 77030-4009, USA
| | - Troy Pearson
- Section of Translational Breast Cancer Research, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kuicheon Choi
- Section of Translational Breast Cancer Research, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jon A Fuson
- Section of Translational Breast Cancer Research, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chandra Bartholomeusz
- Section of Translational Breast Cancer Research, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1354, 1515 Holcombe Boulevard, Houston, TX, 77030-4009, USA
| | | | | | - Debu Tripathy
- Section of Translational Breast Cancer Research, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naoto T Ueno
- Section of Translational Breast Cancer Research, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1354, 1515 Holcombe Boulevard, Houston, TX, 77030-4009, USA.
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