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Wang Y, Ertl C, Schmitt C, Hammann L, Kramer R, Grabmaier U, Schöberl F, Anz D, Piseddu I, Pesch G, Vera J, Froehlich W, Weckbach L, Tomsitz D, Loquai C, Zimmer L, Mangana J, Dummer R, Gutzmer R, Klespe KC, Stege H, Meiss F, Thoms KM, Terheyden P, Bröckelmann PJ, Johnson DB, French LE, Heinzerling L. Stringent monitoring can decrease mortality of immune checkpoint inhibitor induced cardiotoxicity. Front Cardiovasc Med 2024; 11:1408586. [PMID: 38915743 PMCID: PMC11194425 DOI: 10.3389/fcvm.2024.1408586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/14/2024] [Indexed: 06/26/2024] Open
Abstract
Background Immune checkpoint inhibitor (ICI)-induced myocarditis is a rare immune-related adverse event (irAE) with a fatality rate of 40%-46%. However, irMyocarditis can be asymptomatic. Thus, improved monitoring, detection and therapy are needed. This study aims to generate knowledge on pathogenesis and assess outcomes in cancer centers with intensified patient management. Methods Patients with cardiac irAEs from the SERIO registry (www.serio-registry.org) were analyzed for demographics, ICI-related information (type of ICI, therapy line, combination with other drugs, onset of irAE, and tumor response), examination results, irAE treatment and outcome, as well as oncological endpoints. Cardiac biopsies of irMyocarditis cases (n = 12) were analyzed by Nanostring and compared to healthy heart muscle (n = 5) and longitudinal blood sampling was performed for immunophenotyping of irMyocarditis-patients (n = 4 baseline and n = 8 during irAE) in comparison to patients without toxicity under ICI-therapy (n = 4 baseline and n = 7 during ICI-therapy) using flow cytometry. Results A total of 51 patients with 53 cardiac irAEs induced by 4 different ICIs (anti-PD1, anti-PD-L1, anti-CTLA4) were included from 12 centers in 3 countries. Altogether, 83.0% of cardiac irAEs were graded as severe or life-threatening, and 11.3% were fatal (6/53). Thus, in centers with established consequent troponin monitoring, work-up upon the rise in troponin and consequent treatment of irMyocarditis with corticosteroids and -if required-second-line therapy mortality rate is much lower than previously reported. The median time to irMyocarditis was 36 days (range 4-1,074 days) after ICI initiation, whereas other cardiotoxicities, e.g. asystolia or myocardiopathy, occurred much later. The cytokine-mediated signaling pathway was differentially regulated in myocardial biopsies as compared to healthy heart based on enrichment Gene Ontology analysis. Additionally, longitudinal peripheral blood mononuclear cell (PBMC) samples from irMyocarditis-patients indicated ICI-driven enhanced CD4+ Treg cells and reduced CD4+ T cells. Immunophenotypes, particularly effector memory T cells of irMyocarditis-patients differed from those of ICI-treated patients without side effects. LAG3 expression on T cells and PD-L1 expression on dendritic cells could serve as predictive indicators for the development of irMyocarditis. Conclusion Interestingly, our cohort shows a very low mortality rate of irMyocarditis-patients. Our data indicate so far unknown local and systemic immunological patterns in cardiotoxicity.
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Affiliation(s)
- Ying Wang
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Carolin Ertl
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
- SERIO Registry, Munich, Germany
| | - Christina Schmitt
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Linda Hammann
- Division of Clinical Pharmacology, Klinikum der Universität München, Munich, Germany
| | - Rafaela Kramer
- Department of Dermatology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen (UKER), Deutsches Zentrum Immuntherapie (DZI) and Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC-ER-EMN), Erlangen, Germany
| | - Ulrich Grabmaier
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
| | - Florian Schöberl
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - David Anz
- Division of Clinical Pharmacology, Klinikum der Universität München, Munich, Germany
- Department of Medicine II, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ignazio Piseddu
- Division of Clinical Pharmacology, Klinikum der Universität München, Munich, Germany
- Department of Medicine II, LMU University Hospital, LMU Munich, Munich, Germany
| | - Giulia Pesch
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Julio Vera
- Department of Dermatology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen (UKER), Deutsches Zentrum Immuntherapie (DZI) and Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC-ER-EMN), Erlangen, Germany
| | - Waltraud Froehlich
- Division of Clinical Pharmacology, Klinikum der Universität München, Munich, Germany
| | - Ludwig Weckbach
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
| | - Dirk Tomsitz
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Carmen Loquai
- Department of Dermatology, Klinikum Bremen-Ost, Gesundheit Nord gGmbH, Bremen, Germany
| | - Lisa Zimmer
- Department of Dermatology, University Hospital Essen & German Cancer Consortium (DKTK), Partner Site Essen/Duesseldorf, & National Center for Tumor Diseases (NCT)-West, Campus Essen, & Research Alliance Ruhr, Research Center One Health, University Duisburg-Essen, Essen, Germany
| | - Johanna Mangana
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Ralf Gutzmer
- Department of Dermatology, Johannes Wesling Medical Center, Mühlenkreiskliniken (MKK), Ruhr University Bochum, Minden, Germany
| | - Kai-Christian Klespe
- Skin Cancer Center Hannover, Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - Henner Stege
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Frank Meiss
- Faculty of Medicine, Department of Dermatology, Medical Center—University of Freiburg, Freiburg, Germany
| | - Kai-Martin Thoms
- Department of Dermatology, University Medical Center Goettingen, Georg-August-University, Goettingen, Germany
| | | | - Paul J. Bröckelmann
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Douglas B. Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lars E. French
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
- Dr. Philip Frost, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Lucie Heinzerling
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
- SERIO Registry, Munich, Germany
- Department of Dermatology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen (UKER), Deutsches Zentrum Immuntherapie (DZI) and Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC-ER-EMN), Erlangen, Germany
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Long HD, Du YP, Wang LY, Liu GC, Liang SX, Zeng ZH, Lin YE. Successful management of camrelizumab-induced immune-checkpoint-inhibitors-related myocarditis. J Oncol Pharm Pract 2024; 30:597-604. [PMID: 38043937 DOI: 10.1177/10781552231216104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
INTRODUCTION Immune checkpoint inhibitors can cause immune-related toxicity in various systems, with myocarditis being the most severe and life-threatening manifestation. This report presents a case in which myocarditis developed following administration of programmed cell death protein-1 (PD-1) inhibitors therapy. We describe the diagnosis and treatment of this patient in detail. CASE REPORT We present the case of a 59-year-old female diagnosed with post-operative esophageal cancer and hepatic metastases. The patient underwent second-line treatment with domestically-made PD-1 inhibitor, camrelizumab, in combination with paclitaxel (albumin-bound) and carboplatin for two cycles. During the course of treatment, an electrocardiogram (ECG) revealed ST segment elevation in leads II, III, aVF, V2, V3, and V4, along with T wave changes in leads I and aVL. Laboratory examinations showed abnormal levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT). Despite the absence of clinical symptoms, the patient was routinely hospitalized three weeks later. Based on the findings from the ECG, cardiac biomarkers, echocardiography, echocardiogram, cardiac magnetic resonance, and angiography, she was diagnosed with immune-checkpoint-inhibitors-related myocarditis. MANAGEMENT AND OUTCOME The patient received immunoglobulin (0.5 g/kg/day) and was initially given methylprednisolone (1000 mg/day). Methylprednisolone was gradually reduced to 40 mg/day in 2 weeks. During this time, the levels of biomarkers indicative of myocardial injury also exhibited a simultaneous decline. DISCUSSION This case highlights the importance of early detection and prompt intervention, including initiating appropriate steroid therapy and discontinuing of immune checkpoint inhibitors. Such measures can effectively prevent morbidity and mortality, ultimately leading to an improved prognosis.
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Affiliation(s)
- Hui-Dong Long
- Department of Medical Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Yi-Peng Du
- Department of Cardiology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li-Yan Wang
- Department of Urology Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Guan-Cheng Liu
- Department of Ultrasound Room, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Shi-Xiang Liang
- Department of Medical Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Zhao-Hua Zeng
- Department of Cardiology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yun-En Lin
- Department of Pathology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
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3
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Tanabe K, Tanabe J. Role of echocardiography in patients treated with immune checkpoints inhibitors. J Echocardiogr 2023; 21:145-148. [PMID: 37644319 DOI: 10.1007/s12574-023-00621-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Abstract
Immune-related adverse events occurring in the heart (cardiac immune-related adverse events; irAEs) by immune checkpoint inhibitors (ICIs) include myocarditis, arrhythmia, conduction disturbance, pericardial diseases, and takotsubo cardiomyopathy. Cardiac irAEs are rare but life-threatening. In cardio-oncology, the study of cardiac disorders caused by cancer treatment has recently attracted attention, and such studies may elucidate the pathophysiology of cardiac irAEs and contribute to management strategies. This review discusses the pathogenic mechanisms underlying cardiac irAEs and the role of echocardiography in patients treated with ICIs.
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Affiliation(s)
- Kazuaki Tanabe
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Japan.
| | - Junya Tanabe
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Japan
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Paluri RK, Pulipati Y, Regalla DKR. Immune Checkpoint Inhibitors and Their Cardiovascular Adverse Effects. Oncol Rev 2023; 17:11456. [PMID: 38045806 PMCID: PMC10691592 DOI: 10.3389/or.2023.11456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 10/25/2023] [Indexed: 12/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have reshaped and have become a well-established treatment modality for multiple advanced-stage malignancies. ICIs block the immune system regulatory checkpoints, namely CTLA-4 and PD-1/PDL1, which provokes excess immune response against self-antigens. Immune modulation with ICIs can result in diverse immune-related adverse events targeting organ systems. Several cases of ICI-related cardiotoxicity were reported, while the actual incidence was likely underestimated due to heterogeneous clinical presentation. These include, but are not limited to, myocarditis, pericarditis, atherosclerosis, and arrhythmia. EKG, Troponin, Echocardiogram (TTE), and Cardiac MRI (CMRI) are indispensable diagnostic tools to aid in the management of cardiac adverse effects. Herein, we review the ICI-mediated cardiovascular adverse events, diagnosis, treatment strategies, and reintroduction of ICIs post-cardiotoxicity.
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Affiliation(s)
- Ravi Kumar Paluri
- Department of Hematology-Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States
| | - Yochitha Pulipati
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA, United States
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5
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Lessomo FYN, Mandizadza OO, Mukuka C, Wang ZQ. A comprehensive review on immune checkpoint inhibitors induced cardiotoxicity characteristics and associated factors. Eur J Med Res 2023; 28:495. [PMID: 37941006 PMCID: PMC10631013 DOI: 10.1186/s40001-023-01464-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023] Open
Abstract
Newly approved cancer drugs called ICIs have shown remarkable success in improving patient survival rates, but they also have the potential for inflammatory and immune-related side effects, including those affecting the cardiovascular system. Research has been conducted to understand the development of these toxicities and identify risk factors. This review focuses on the characteristics of ICI-induced cardiotoxicity and discusses the reported risk factors. It is important for cardio-oncologists to understand the basic concepts of these drugs to better understand how cardiotoxicities occur. It might be hard to find reports, where all patients treated with ICIs had developed cardiac toxicity, because there could be other existing and variable factors that influence the likelihood or risk of developing cardiotoxicity during treatment. Various clinical parameters have been explored as potential risk factors, and further investigation is needed through large-scale studies.
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Affiliation(s)
| | | | | | - Zhi-Quan Wang
- Cardiology Department, Zhongnan Hospital of Wuhan University, Wuhan, China.
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6
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Liu X, Zeng Z, Cao J, Li X, Muhetaer M, Jin Z, Cai H, Lu Z. Sintilimab-Induced Myocarditis in a Patient with Gastric Cancer: A Case Report and Literature Review. J Cardiovasc Dev Dis 2023; 10:422. [PMID: 37887869 PMCID: PMC10607029 DOI: 10.3390/jcdd10100422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/15/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as a powerful and efficacious therapeutic approach for many cancer patients. Sintilimab is a fully human IgG4 monoclonal antibody that binds with programmed cell death receptor-1 (PD-1) to block its interaction with ligands, thereby enhancing the antitumor effects of T cells. However, ICIs may induce immune-related adverse events (irAEs) in various systems and organs, with fulminant myocarditis being the most severe one. We report the case of a 45-year-old female with gastric cancer who developed chest pain two weeks after chemotherapy with sintilimab; she was diagnosed with immune-associated fulminant myocarditis and experienced an Adams-Stokes syndrome attack in the hospital. Eventually, she was discharged after being treated with methylprednisolone, immunoglobulin, and an IABP.
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Affiliation(s)
- Xin Liu
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Ziyue Zeng
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Jianlei Cao
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Xianqing Li
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Muheremu Muhetaer
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Zhili Jin
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Huanhuan Cai
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Zhibing Lu
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
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Procyk G, Grodzka O, Procyk M, Gąsecka A, Głuszek K, Wrzosek M. MicroRNAs in Myocarditis-Review of the Preclinical In Vivo Trials. Biomedicines 2023; 11:2723. [PMID: 37893097 PMCID: PMC10604573 DOI: 10.3390/biomedicines11102723] [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: 09/06/2023] [Revised: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Myocarditis is an inflammatory heart disease with viruses as the most common cause. Regardless of multiple studies that have recently been conducted, the diagnostic options still need to be improved. Although endomyocardial biopsy is known as a diagnostic gold standard, it is invasive and, thus, only sometimes performed. Novel techniques of cardiac magnetic resonance are not readily available. Therapy in viral infections is based mainly on symptomatic treatment, while steroids and intravenous immunoglobulins are used in autoimmune myocarditis. The effectiveness of neither of these methods has been explicitly proven to date. Therefore, novel diagnostic and therapeutic strategies are highly needed. MiRNAs are small, non-coding molecules that regulate fundamental cell functions, including differentiation, metabolism, and apoptosis. They present altered levels in different diseases, including myocarditis. Numerous studies investigating the role of miRNAs in myocarditis have already been conducted. In this review, we discussed only the original preclinical in vivo research. We eventually included 30 studies relevant to the discussed area. The altered miRNA levels have been observed, including upregulation and downregulation of different miRNAs in the mice models of myocarditis. Furthermore, the administration of mimics or inhibitors of particular miRNAs was shown to significantly influence inflammation, morphology, and function of the heart and overall survival. Finally, some studies presented prospective advantages in vaccine development.
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Affiliation(s)
- Grzegorz Procyk
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland
- Doctoral School, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Olga Grodzka
- Department of Neurology, Faculty of Medicine and Dentistry, Medical University of Warsaw, Ceglowska 80, 01-809 Warsaw, Poland
| | - Marcelina Procyk
- Faculty of Biology and Biotechnology, Warsaw University of Life Sciences (WULS-SGGW), 02-787 Warsaw, Poland
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland
| | - Katarzyna Głuszek
- Collegium Medicum, Jan Kochanowski University of Kielce, 25-406 Kielce, Poland
| | - Małgorzata Wrzosek
- Department of Biochemistry and Pharmacogenomics, Medical University of Warsaw, Banacha 1, 02-097 Warsaw, Poland
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Horiguchi H, Kadomatsu T, Yamashita T, Yumoto S, Terada K, Sato M, Morinaga J, Miyata K, Oike Y. ANGPTL2 promotes immune checkpoint inhibitor-related murine autoimmune myocarditis. Commun Biol 2023; 6:965. [PMID: 37736764 PMCID: PMC10517162 DOI: 10.1038/s42003-023-05338-4] [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: 04/17/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023] Open
Abstract
Use of immune checkpoint inhibitors (ICIs) as cancer immunotherapy advances rapidly in the clinic. Despite their therapeutic benefits, ICIs can cause clinically significant immune-related adverse events (irAEs), including myocarditis. However, the cellular and molecular mechanisms regulating irAE remain unclear. Here, we investigate the function of Angiopoietin-like protein 2 (ANGPTL2), a potential inflammatory mediator, in a mouse model of ICI-related autoimmune myocarditis. ANGPTL2 deficiency attenuates autoimmune inflammation in these mice, an outcome associated with decreased numbers of T cells and macrophages. We also show that cardiac fibroblasts express abundant ANGPTL2. Importantly, cardiac myofibroblast-derived ANGPTL2 enhances expression of chemoattractants via the NF-κB pathway, accelerating T cell recruitment into heart tissues. Our findings suggest an immunostimulatory function for ANGPTL2 in the context of ICI-related autoimmune inflammation and highlight the pathophysiological significance of ANGPTL2-mediated cardiac myofibroblast/immune cell crosstalk in enhancing autoimmune responses. These findings overall provide insight into mechanisms regulating irAEs.
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Affiliation(s)
- Haruki Horiguchi
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan
- Department of Aging and Geriatric Medicine, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan
| | - Tsuyoshi Kadomatsu
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan.
- Center for Metabolic Regulation of Healthy Aging (CMHA), Graduate School of Medical Sciences, Kumamoto University, Kumamoto, 860-8556, Japan.
| | - Tomoya Yamashita
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan
| | - Shinsei Yumoto
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, 860-8556, Japan
| | - Kazutoyo Terada
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging (CMHA), Graduate School of Medical Sciences, Kumamoto University, Kumamoto, 860-8556, Japan
| | - Michio Sato
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan
| | - Jun Morinaga
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan
| | - Keishi Miyata
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging (CMHA), Graduate School of Medical Sciences, Kumamoto University, Kumamoto, 860-8556, Japan
| | - Yuichi Oike
- Department of Molecular Genetics, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan.
- Department of Aging and Geriatric Medicine, Graduate School of Medical Science, Kumamoto University, Kumamoto, 860-8556, Japan.
- Center for Metabolic Regulation of Healthy Aging (CMHA), Graduate School of Medical Sciences, Kumamoto University, Kumamoto, 860-8556, Japan.
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Rocca C, Soda T, De Francesco EM, Fiorillo M, Moccia F, Viglietto G, Angelone T, Amodio N. Mitochondrial dysfunction at the crossroad of cardiovascular diseases and cancer. J Transl Med 2023; 21:635. [PMID: 37726810 PMCID: PMC10507834 DOI: 10.1186/s12967-023-04498-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 09/01/2023] [Indexed: 09/21/2023] Open
Abstract
A large body of evidence indicates the existence of a complex pathophysiological relationship between cardiovascular diseases and cancer. Mitochondria are crucial organelles whose optimal activity is determined by quality control systems, which regulate critical cellular events, ranging from intermediary metabolism and calcium signaling to mitochondrial dynamics, cell death and mitophagy. Emerging data indicate that impaired mitochondrial quality control drives myocardial dysfunction occurring in several heart diseases, including cardiac hypertrophy, myocardial infarction, ischaemia/reperfusion damage and metabolic cardiomyopathies. On the other hand, diverse human cancers also dysregulate mitochondrial quality control to promote their initiation and progression, suggesting that modulating mitochondrial homeostasis may represent a promising therapeutic strategy both in cardiology and oncology. In this review, first we briefly introduce the physiological mechanisms underlying the mitochondrial quality control system, and then summarize the current understanding about the impact of dysregulated mitochondrial functions in cardiovascular diseases and cancer. We also discuss key mitochondrial mechanisms underlying the increased risk of cardiovascular complications secondary to the main current anticancer strategies, highlighting the potential of strategies aimed at alleviating mitochondrial impairment-related cardiac dysfunction and tumorigenesis. It is hoped that this summary can provide novel insights into precision medicine approaches to reduce cardiovascular and cancer morbidities and mortalities.
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Affiliation(s)
- Carmine Rocca
- Cellular and Molecular Cardiovascular Pathophysiology Laboratory, Department of Biology, E and E.S. (DiBEST), University of Calabria, Arcavacata di Rende, 87036, Cosenza, Italy
| | - Teresa Soda
- Department of Health Science, University Magna Graecia of Catanzaro, 88100, Catanzaro, Italy
| | - Ernestina Marianna De Francesco
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, 95122, Catania, Italy
| | - Marco Fiorillo
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036, Rende, Italy
| | - Francesco Moccia
- Laboratory of General Physiology, Department of Biology and Biotechnology "L. Spallanzani", University of Pavia, 27100, Pavia, Italy
| | - Giuseppe Viglietto
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, 88100, Catanzaro, Italy
| | - Tommaso Angelone
- Cellular and Molecular Cardiovascular Pathophysiology Laboratory, Department of Biology, E and E.S. (DiBEST), University of Calabria, Arcavacata di Rende, 87036, Cosenza, Italy.
- National Institute of Cardiovascular Research (I.N.R.C.), 40126, Bologna, Italy.
| | - Nicola Amodio
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, 88100, Catanzaro, Italy.
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Integrated Single-Cell and RNA Sequencing Analysis Identifies Key Immune Cell and Dendritic Cells Associated Genes Participated in Myocarditis. J Immunol Res 2022; 2022:8655343. [PMID: 36226312 PMCID: PMC9550476 DOI: 10.1155/2022/8655343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/17/2022] [Indexed: 11/18/2022] Open
Abstract
Myocarditis is a complex disease characterized by myocardial inflammatory cell infiltration. The purpose of our study was to investigate the gene and single-cell signature to explore the involvement of immune cells in myocarditis. Gene expressions merged from GSE35182 and GSE35182 datasets were subjected to differential expression gene (DEG) analysis and PPI network construction. The correlation analysis of DEGs with immune cell infiltration was performed. Single-cell RNA sequencing (scRNA-seq) was downloaded from GSE174458. A total of 58 DEGs were identified, including 51 DEGs upregulated and 7 DEGs downregulated in the myocarditis group compared with the control group. GO and KEGG enrichment analyses revealed that myocarditis triggered DEGs mainly involved in immune-related processes and pathways. PPI network analysis identified 20 central hub genes. Occurrence of myocarditis induced significant enrichment of conventional dendritic cell 2 (cDC2), plasmacytoid DC, and plasma cell in myocardial tissue. Mmp12, Gpnmb, and Atp6v0d2 expressions were positively correlated with cDC abundance, of which only Mmp1 and Gpnmb were shared with hub gene list. A total of 20972 cells in scRNA-seq yielded 26 cell clusters and annotated 9 cell types, including fibroblasts, neutrophils, stromal cells, monocytes, basophils, B cells, natural killer T cells, innate lymphoid cells, and T cells, and only proportion of natural killer T cells and monocytes were higher in the myocarditis than in control. Monocytes annotated 3 subclusters including DC, macrophage, and monocytes. Hub genes of Ctss, Mpeg1, Cybb, H2-Ab1, Ly86, CD74, and Lgals3 were highly expressed in monocytes cluster. Among DC-correlated DEGs, Mmp12 was mainly expressed in monocyte cluster, and Gpnmb was mainly expressed in fibroblast cluster, whereas Atp6v0d2 expression has a weaker signal and weaker cell preference. In conclusion, DC infiltration and its associated pivotal genes may be responsible for progression of myocarditis. Our study expands and provides novel information on the immune cell engagement of myocarditis.
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11
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Cozma A, Sporis ND, Lazar AL, Buruiana A, Ganea AM, Malinescu TV, Berechet BM, Fodor A, Sitar-Taut AV, Vlad VC, Negrean V, Orasan OH. Cardiac Toxicity Associated with Immune Checkpoint Inhibitors: A Systematic Review. Int J Mol Sci 2022; 23:ijms231810948. [PMID: 36142866 PMCID: PMC9502843 DOI: 10.3390/ijms231810948] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/09/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are an important advancement in the field of cancer treatment, significantly improving the survival of patients with a series of advanced malignancies, like melanoma, non-small cell lung cancer (NSCLC), hepatocellular carcinoma (HCC), renal cell carcinoma (RCC), and Hodgkin lymphoma. ICIs act upon T lymphocytes and antigen-presenting cells, targeting programmed cell death protein 1 (PD1), programmed cell death protein ligand 1 (PD-L1), and cytotoxic T-lymphocyte antigen 4 (CTLA-4), breaking the immune tolerance of the T cells against malignant cells and enhancing the body's own immune response. A variety of cardiac-adverse effects are associated with ICI-based treatment, including pericarditis, arrhythmias, cardiomyopathy, and acute coronary syndrome, with myocarditis being the most studied due to its often-unexpected onset and severity. Overall, Myocarditis is rare but presents an immune-related adverse event (irAE) that has a high fatality rate. Considering the rising number of oncological patients treated with ICIs and the severity of their potential adverse effects, a good understanding and continuous investigation of cardiac irAEs is of the utmost importance. This systematic review aimed to revise recent publications (between 2016-2022) on ICI-induced cardiac toxicities and highlight the therapeutical approach and evolution in the selected cases.
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Affiliation(s)
- Angela Cozma
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Nicolae Dan Sporis
- Department of Medical Oncology, Prof. Dr. I. Chiricuta Oncology Institute, 400015 Cluj-Napoca, Romania
| | - Andrada Luciana Lazar
- Department of Dermatology, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Andrei Buruiana
- Department of Medical Oncology, Prof. Dr. I. Chiricuta Oncology Institute, 400015 Cluj-Napoca, Romania
- Correspondence:
| | - Andreea Maria Ganea
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Toma Vlad Malinescu
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Bianca Mihaela Berechet
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Adriana Fodor
- Clinical Centre of Diabetes, Nutrition and Metabolic Disease, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Adela Viviana Sitar-Taut
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Vasile Calin Vlad
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Vasile Negrean
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Olga Hilda Orasan
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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12
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Yin N, Liu X, Ye X, Song W, Lu J, Chen X. PD-1 inhibitor therapy causes multisystem immune adverse reactions: a case report and literature review. Front Oncol 2022; 12:961266. [PMID: 36119464 PMCID: PMC9478917 DOI: 10.3389/fonc.2022.961266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
Immune checkpoint inhibitors(ICIs), including cytotoxic T-lymphocyte antigen 4 (anti-CTLA-4), programmed cell death protein 1 and its ligand (PD-1/PD-L1) inhibitors, have been shown to have antitumor activity in various solid tumors. Their mechanism of action is to selectively restore and normalize the body’s immune reponses by disrupting the immunosuppressive signals mediated by PD-1, PD-L1 and CTLA-4 in the tumor microenvironment. With the increase in clinical applications of ICIs, reports of immune-related adverse events (irAEs) have also increased. This article reports a case of a lung cancer patient who developed multisystemic adverse effects after PD-1 inhibitor application: myocarditis, myositis and thrombocytopenia, and analyzes the role of Interleukin 6(IL-6)in the management of irAEs. Despite the patient’s eventual discontinuation of antitumor therapy due to severe irAEs, a significant and durable therapeutic response was observed.
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13
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Myocarditis Induced by Immunotherapy in Metastatic Melanoma—Review of Literature and Current Guidelines. J Clin Med 2022; 11:jcm11175182. [PMID: 36079112 PMCID: PMC9457343 DOI: 10.3390/jcm11175182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Immunotherapy is a widely used treatment modality in oncology. Immune checkpoint inhibitors, as a part of immunotherapy, caused a revolution in oncology, especially in melanoma therapy, due to the significant prolongation of patients’ overall survival. These drugs act by activation of inhibited immune responses of T lymphocytes against cancer cells. The mechanism responsible for the therapy’s high efficacy is also involved in immune tolerance of the patient’s own tissues. The administration of ICI therapy to a patient can cause severe immune reactions against non-neoplastic cells. Among them, cardiotoxicity seems most important due to the high mortality rate. In this article, we present the history of a 79 year-old patient diagnosed with melanoma who died due to myocarditis induced by ICI therapy, despite the fast administration of recommended immunosuppressive therapy, as an illustration of possible adverse events of ICI. Additionally, we summarize the mechanism, risk factors, biomarkers, and clinical data from currently published guidelines and studies about ICI-related myocarditis. The fast recognition of this fatal adverse effect of therapy may accelerate the rapid introduction of treatment and improve patients’ outcomes.
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14
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Topriceanu CC, Pierce I, Moon JC, Captur G. T 2 and T 2⁎ mapping and weighted imaging in cardiac MRI. Magn Reson Imaging 2022; 93:15-32. [PMID: 35914654 DOI: 10.1016/j.mri.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022]
Abstract
Cardiac imaging is progressing from simple imaging of heart structure and function to techniques visualizing and measuring underlying tissue biological changes that can potentially define disease and therapeutic options. These techniques exploit underlying tissue magnetic relaxation times: T1, T2 and T2*. Initial weighting methods showed myocardial heterogeneity, detecting regional disease. Current methods are now fully quantitative generating intuitive color maps that do not only expose regionality, but also diffuse changes - meaning that between-scan comparisons can be made to define disease (compared to normal) and to monitor interval change (compared to old scans). T1 is now familiar and used clinically in multiple scenarios, yet some technical challenges remain. T2 is elevated with increased tissue water - oedema. Should there also be blood troponin elevation, this oedema likely reflects inflammation, a key biological process. T2* falls in the presence of magnetic/paramagnetic materials - practically, this means it measures tissue iron, either after myocardial hemorrhage or in myocardial iron overload. This review discusses how T2 and T2⁎ imaging work (underlying physics, innovations, dependencies, performance), current and emerging use cases, quality assurance processes for global delivery and future research directions.
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Affiliation(s)
- Constantin-Cristian Topriceanu
- Cardiac MRI Unit, Barts Heart Centre, West Smithfield, London, UK; UCL Institute of Cardiovascular Science, University College London, London, UK; UCL MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Iain Pierce
- Cardiac MRI Unit, Barts Heart Centre, West Smithfield, London, UK; UCL Institute of Cardiovascular Science, University College London, London, UK
| | - James C Moon
- Cardiac MRI Unit, Barts Heart Centre, West Smithfield, London, UK; UCL Institute of Cardiovascular Science, University College London, London, UK
| | - Gabriella Captur
- Cardiac MRI Unit, Barts Heart Centre, West Smithfield, London, UK; UCL Institute of Cardiovascular Science, University College London, London, UK; UCL MRC Unit for Lifelong Health and Ageing, University College London, London, UK; The Royal Free Hospital, Centre for Inherited Heart Muscle Conditions, Cardiology Department, Pond Street, Hampstead, London, UK.
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15
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Murakata Y, Tajiri K. A Diverse Range of Cardiac Adverse Events Associated with Immune Checkpoint Inhibitor Therapy. Intern Med 2022; 61:2099-2100. [PMID: 35283387 PMCID: PMC9381357 DOI: 10.2169/internalmedicine.9018-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Yoshiko Murakata
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan
| | - Kazuko Tajiri
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan
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16
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Rubio-Infante N, Ramírez-Flores YA, Castillo EC, Lozano O, García-Rivas G, Torre-Amione G. A Systematic Review of the Mechanisms Involved in Immune Checkpoint Inhibitors Cardiotoxicity and Challenges to Improve Clinical Safety. Front Cell Dev Biol 2022; 10:851032. [PMID: 35433707 PMCID: PMC9006991 DOI: 10.3389/fcell.2022.851032] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/02/2022] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that block CTLA-4, PD-1, or PD-L1 and induce the activation of the immune system against cancer. Despite the efficacy of ICIs, which has improved the oncotherapy for patients with a variety of malignancies, several immune-related adverse events (irAEs) have been described, including those affecting the heart. Cardiac irAEs after ICI therapies, including myocarditis, can become life-threatening, and their pathogenic mechanisms remain unclear. Here, a systematic analysis was performed regarding the potential immune mechanisms underlying cardiac irAEs based on the immune adverse events induced by the ICIs: 1) recruitment of CD4+ and CD8+ T cells, 2) autoantibody-mediated cardiotoxicity, and 3) inflammatory cytokines. Furthermore, the impact of dual therapies in ICI-induced cardiac irAEs and the potential risk factors are reviewed. We propose that self-antigens released from cardiac tissues or cancer cells and the severity/advancement of cancer disease have an important role in ICI cardiotoxicity.
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Affiliation(s)
- Nestor Rubio-Infante
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
| | - Yoel Adbel Ramírez-Flores
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
| | - Elena Cristina Castillo
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
| | - Omar Lozano
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Investigación Biomédica, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
- Tecnologico de Monterrey, The Institute for Obesity Research, Monterrey, Mexico
| | - Gerardo García-Rivas
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Investigación Biomédica, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
- Tecnologico de Monterrey, The Institute for Obesity Research, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Medicina Funcional, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
| | - Guillermo Torre-Amione
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Investigación Biomédica, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
- Tecnologico de Monterrey, The Institute for Obesity Research, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Medicina Funcional, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
- The Methodist Hospital, Cornell University, Houston, TX, United States
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17
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Tajiri K, Sekine I. Atherosclerotic cardiovascular events associated with immune checkpoint inhibitors in cancer patients. Jpn J Clin Oncol 2022; 52:659-664. [DOI: 10.1093/jjco/hyac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Immune checkpoint inhibitors have demonstrated significant clinical benefits in many cancers, and the use of these drugs is rapidly expanding. Unfortunately, these agents can induce a wide range of immune-related adverse events through the activation of immune responses in non-target organs, including the cardiovascular system. Among cardiovascular immune-related adverse events, myocarditis is the most established and biologically plausible cardiac complication of immune checkpoint inhibitors therapy with immune-related pathophysiology. In contrast, atherosclerotic cardiovascular diseases, such as myocardial infarction and ischemic stroke, were not previously recognized as a part of the immune-related adverse event spectrum. However, there is now increasing preclinical and clinical evidence that suggests a possible correlation between immune checkpoint inhibitors therapy and atherosclerotic cardiovascular events, and cardiovascular disease is increasingly recognized as a toxicity of ICIs. Results from animal studies suggest that the blockade of the cytotoxic T-lymphocyte antigen 4 or programmed cell death protein 1 pathway plays a relevant role in promoting the progression of atherosclerotic lesions. Several clinical studies have reported an increased incidence of atherosclerotic vascular events after immune checkpoint inhibitor administration. Our findings suggest that clinicians should (i) recognize that immune checkpoint inhibitors can exacerbate atherosclerosis, (ii) consider the management of cardiovascular risk factors and (iii) perform periodic screening in patients receiving immune checkpoint inhibitors.
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Affiliation(s)
- Kazuko Tajiri
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba
| | - Ikuo Sekine
- Department of Medical Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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18
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Brumberger ZL, Branch ME, Klein MW, Seals A, Shapiro MD, Vasu S. Cardiotoxicity risk factors with immune checkpoint inhibitors. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2022; 8:3. [PMID: 35277208 PMCID: PMC8915459 DOI: 10.1186/s40959-022-00130-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 02/21/2022] [Indexed: 12/18/2022]
Abstract
Background Checkpoint-inhibitor immunotherapies have had a profound effect in the treatment of cancer by inhibiting down-regulation of T-cell response to malignancy. The cardiotoxic potential of these agents was first described in murine models and, more recently, in numerous clinical case reports of pericarditis, myocarditis, pericardial effusion, cardiomyopathy, and new arrhythmias. The objective of our study was to determine the frequency of and associated risk factors for cardiotoxic events in patients treated with immune checkpoint inhibitors. Methods Medical records of patients who underwent immunotherapy with durvalumab, ipilimumab, nivolumab, and pembrolizumab at Wake Forest Baptist Health were reviewed. We collected retrospective data regarding sex, cancer type, age, and cardiovascular disease risk factors and medications. We aimed to identify new diagnoses of heart failure, atrial fibrillation, ventricular fibrillation/tachycardia, myocarditis, and pericarditis after therapy onset. To assess the relationship between CVD risk factors and the number of cardiac events, a multivariate model was applied using generalized linear regression. Incidence rate ratios were calculated for every covariate along with the adjusted P-value. We applied a multivariate model using logistic regression to assess the relationship between CVD risk factors and mortality. Odds ratios were calculated for every covariate along with the adjusted P-value. Adjusted P-values were calculated using multivariable regression adjusting for other covariates. Results Review of 538 medical records revealed the following events: 3 ventricular fibrillation/tachycardia, 12 pericarditis, 11 atrial fibrillation with rapid ventricular rate, 0 myocarditis, 8 heart failure. Significant risk factors included female gender, African American race, and tobacco use with IRR 3.34 (95% CI 1.421, 7.849; P = 0.006), IRR 3.39 (95% CI 1.141, 10.055; P = 0.028), and IRR 4.21 (95% CI 1.289, 13.763; P = 0.017) respectively. Conclusions Our study revealed 34 significant events, most frequent being pericarditis (2.2%) and atrial fibrillation (2.0%) with strongest risk factors being female gender, African American race, and tobacco use. Patients who meet this demographic, particularly those with planned pembrolizumab treatment, may benefit from early referral to a cardio-oncologist. Further investigation is warranted on the relationship between CTLA-4 and PD-L1 expression and cardiac adverse events with ICIs, particularly for these subpopulations.
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Affiliation(s)
- Zachary L Brumberger
- Department of Internal Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Mary E Branch
- Department of Internal Medicine, Section On Cardiovascular Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Max W Klein
- Department of Internal Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Austin Seals
- Department of Internal Medicine, Section On Cardiovascular Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Michael D Shapiro
- Department of Internal Medicine, Section On Cardiovascular Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Sujethra Vasu
- Department of Internal Medicine, Section On Cardiovascular Medicine, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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19
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Sun JY, Qu Q, Lou YX, Hua Y, Sun GZ, Sun W, Kong XQ. Cardiotoxicity in cancer immune-checkpoint therapy: Mechanisms, clinical evidence, and management strategies. Int J Cardiol 2021; 344:170-178. [PMID: 34563597 DOI: 10.1016/j.ijcard.2021.09.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/30/2021] [Accepted: 09/20/2021] [Indexed: 12/17/2022]
Abstract
Immune-checkpoint inhibitors (ICIs), a unique antibody-based therapeutic strategy, have revolutionized the treatment landscape of solid and hematological cancers. Despite the proven benefits of ICIs, the cardiotoxicity from unspecific immune activation (uncommon but potentially fatal) is a continuing concern. Accumulating preclinical research has demonstrated that ICIs initiate inflammation in the myocardium, while clinically significant cardiotoxicity were reported in few patients receiving ICI therapy, probably due to the low incidence and unspecific symptoms. The subtle signs and symptoms (e.g., chest pain, dizziness, and dyspnea) were likely attributed to cancer and/or non-cardiac events by previous studies, thus limiting the understanding of the incidence, outcomes, risk factors, and management of ICI-related cardiotoxicity. The heterogeneous clinical presentation and complex diagnostic procedure further make it challenging to accurately identify ICI-related cardiac events in clinical trials. Therefore, ICI-related cardiotoxicity, whose incidence is probably underestimated, has not been well recognized. In this article, we provide an overview of potential mechanisms underlying ICI-related cardiotoxicity and review accumulating clinical evidence of ICI-related cardiotoxicity, with a focus on myocarditis. Moreover, we discuss possible strategies to manage ICI-related cardiotoxicity and highlight the importance of developing cardio-oncology.
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Affiliation(s)
- Jin-Yu Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Qiang Qu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Yu-Xuan Lou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Yang Hua
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Guo-Zhen Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Wei Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China..
| | - Xiang-Qing Kong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China..
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20
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Chaloulos-Iakovidis P, Aicher ML, Chilver-Stainer L. [An Unusual Cause for a Bilateral Ptosis]. PRAXIS 2021; 110:643-646. [PMID: 34465196 DOI: 10.1024/1661-8157/a003706] [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: 06/13/2023]
Abstract
An Unusual Cause for a Bilateral Ptosis Abstract. Immune-checkpoint-inhibitors are increasingly used in various malignancies. Autoimmune side effects such as colitis, hepatitis or skin reactions are well known, on the other hand neurological autoimmune complications such as myasthenic syndromes, myopathies or overlap syndromes with potentially life-threatening complications are less common and not well understood. A precise diagnosis has far reaching therapeutic consequences. Here we present the case of a patient under immune checkpoint inhibitor therapy, in which the diagnosis, due to the presence of overlap symptoms, is shown to be challenging. However, it was crucial to find the correct diagnosis in order to choose the proper therapy.
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Affiliation(s)
| | - Marie Louise Aicher
- Universitätsklinik für Neurologie, Inselspital, Universitätsspital Bern, Bern
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21
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Rikhi R, Karnuta J, Hussain M, Collier P, Funchain P, Tang WHW, Chan TA, Moudgil R. Immune Checkpoint Inhibitors Mediated Lymphocytic and Giant Cell Myocarditis: Uncovering Etiological Mechanisms. Front Cardiovasc Med 2021; 8:721333. [PMID: 34434981 PMCID: PMC8381278 DOI: 10.3389/fcvm.2021.721333] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/14/2021] [Indexed: 12/26/2022] Open
Abstract
The advent of immune checkpoint inhibitors (ICIs) has revolutionized the field of oncology, but these are associated with immune related adverse events. One such adverse event, is myocarditis, which has limited the continued immunosuppressive treatment options in patients afflicted by the disease. Pre-clinical and clinical data have found that specific ICI targets and precipitate distinct myocardial infiltrates, consistent with lymphocytic or giant cell myocarditis. Specifically, it has been reported that CTLA-4 inhibition preferentially results in giant cell myocarditis with a predominately CD4+ T cell infiltrate and PD-1 inhibition leads to lymphocytic myocarditis, with a predominately CD8+ T cell infiltrate. Our manuscript discusses the latest literature surrounding ICI pathways and targets, while detailing proposed mechanisms behind ICI mediated myocarditis.
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Affiliation(s)
- Rishi Rikhi
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, United States.,Department of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Jaret Karnuta
- Department of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Muzna Hussain
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Patrick Collier
- Department of Medicine, Case Western Reserve University, Cleveland, OH, United States.,Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Pauline Funchain
- Department of Medicine, Case Western Reserve University, Cleveland, OH, United States.,Department of Hematology and Medical Oncology, Taussig Cancer Center Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Wai Hong Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Timothy A Chan
- Center for Immunotherapy and Precision Immuno-Oncology, Lerner Research Institute, Cleveland, OH, United States
| | - Rohit Moudgil
- Department of Medicine, Case Western Reserve University, Cleveland, OH, United States.,Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
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22
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Nierstedt RT, Yeahia R, Barnett KM. Unanticipated Myocarditis in a Surgical Patient Treated With Pembrolizumab: A Case Report. A A Pract 2021; 14:e01177. [PMID: 32132361 DOI: 10.1213/xaa.0000000000001177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We report a case of fatal immune checkpoint inhibitor (ICI)-associated myocarditis in a 77-year-old man with metastatic non-small cell lung cancer (NSCLC) who presented for mediport placement at our outpatient surgical center. He denied any cardiac complaints and had a previously normal electrocardiogram (EKG) off treatment. Intraoperatively and postoperatively, he displayed cardiac rhythm abnormalities. The patient was then transferred to a tertiary facility, where he expired within 48 hours. As cancer immunotherapy becomes increasingly prominent, ICI-associated myocarditis should be considered a potentially critical contributor to perioperative cardiac morbidity and mortality.
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Affiliation(s)
- Ryan T Nierstedt
- From the Oakland University William Beaumont School of Medicine, Rochester, Michigan.,Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center Monmouth Ambulatory Surgery Center, Middletown, New Jersey
| | - Rubaya Yeahia
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center Monmouth Ambulatory Surgery Center, Middletown, New Jersey.,New York Medical College, Valhalla, New York
| | - Kara M Barnett
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center Monmouth Ambulatory Surgery Center, Middletown, New Jersey
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23
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Imanaka-Yoshida K. Tenascin-C in Heart Diseases-The Role of Inflammation. Int J Mol Sci 2021; 22:ijms22115828. [PMID: 34072423 PMCID: PMC8198581 DOI: 10.3390/ijms22115828] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 12/20/2022] Open
Abstract
Tenascin-C (TNC) is a large extracellular matrix (ECM) glycoprotein and an original member of the matricellular protein family. TNC is transiently expressed in the heart during embryonic development, but is rarely detected in normal adults; however, its expression is strongly up-regulated with inflammation. Although neither TNC-knockout nor -overexpressing mice show a distinct phenotype, disease models using genetically engineered mice combined with in vitro experiments have revealed multiple significant roles for TNC in responses to injury and myocardial repair, particularly in the regulation of inflammation. In most cases, TNC appears to deteriorate adverse ventricular remodeling by aggravating inflammation/fibrosis. Furthermore, accumulating clinical evidence has shown that high TNC levels predict adverse ventricular remodeling and a poor prognosis in patients with various heart diseases. Since the importance of inflammation has attracted attention in the pathophysiology of heart diseases, this review will focus on the roles of TNC in various types of inflammatory reactions, such as myocardial infarction, hypertensive fibrosis, myocarditis caused by viral infection or autoimmunity, and dilated cardiomyopathy. The utility of TNC as a biomarker for the stratification of myocardial disease conditions and the selection of appropriate therapies will also be discussed from a clinical viewpoint.
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Affiliation(s)
- Kyoko Imanaka-Yoshida
- Department of Pathology and Matrix Biology, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan;
- Mie University Research Center for Matrix Biology, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
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24
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Jacob JB, Jacob MK, Parajuli P. Review of immune checkpoint inhibitors in immuno-oncology. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2021; 91:111-139. [PMID: 34099106 DOI: 10.1016/bs.apha.2021.01.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Tumor cells predominantly express self-antigens and overcoming self-tolerance is the primary challenge to effective immunotherapy. Tumors also express ligands for co-inhibitory molecules on immune cells, in order to suppress anti-tumor immunity. Over a decade ago, the first antibodies generated to block the co-inhibitory molecule CTLA-4 was tested in patients with metastatic melanoma. Results from this landmark trial have informed not only the current landscape of checkpoint blockade but also the way in which immunotherapy trial outcomes are determined. Antibodies targeting PD-1 and its ligand, PD-L1, soon followed and use of these checkpoint inhibitors (ICIs) have expanded exponentially. ICI treatment has shown long-lasting clinical benefit in several tumor types and patients refractory to other treatments can often respond to ICI therapy. On the other hand, in some tumor types, the response to ICI is short-lived and tumors eventually recur. Current clinical trials are focused on enhancing anti-tumor effects through combinations of multiple ICIs with agents which cause tumor death, particularly in solid tumors, in order to enhance antigen presentation. It is also important to define which patients will respond to therapy with ICIs as over half of all patients suffer from immune-related adverse events (irAE), some of which are severe and long-lasting.
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Affiliation(s)
- Jennifer B Jacob
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, MI, United States.
| | - Mark K Jacob
- Michigan State University School of Human Medicine, East Lansing, MI, United States
| | - Prahlad Parajuli
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, MI, United States
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25
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Kadowaki H, Akazawa H, Ishida J, Komuro I. Mechanisms and Management of Immune Checkpoint Inhibitor-Related Cardiac Adverse Events. JMA J 2021; 4:91-98. [PMID: 33997442 PMCID: PMC8118963 DOI: 10.31662/jmaj.2021-0001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/15/2021] [Indexed: 12/31/2022] Open
Abstract
Onco-cardiology recently emerged as a novel discipline to provide effective cardioprotective care against cancer therapeutics-related cardiac adverse events (CAEs) and support the continuity of optimal cancer treatment. Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy and dramatically improved outcomes in patients with advanced or refractory cancers. However, ICIs intrinsically stimulate systemic immune responses and can potentially induce a spectrum of immune-related adverse events (irAEs), which can affect any organs of the body. The manifestation of cardiac irAEs includes myocarditis, arrhythmias and conduction abnormalities, and pericardial diseases. Takotsubo-like cardiomyopathy is also included as a manifestation of ICI-related CAEs, but the pathophysiological relevance is unclear. Although the incidence is rare, ICI-related CAEs are life-threatening and potentially fatal. Elucidating pathophysiology and establishing management measures of ICI-related CAEs are one of the most urgent challenges in the field of onco-cardiology.
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Affiliation(s)
- Hiroshi Kadowaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Akazawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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26
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Tajiri K, Yonebayashi S, Li S, Ieda M. Immunomodulatory Role of Tenascin-C in Myocarditis and Inflammatory Cardiomyopathy. Front Immunol 2021; 12:624703. [PMID: 33692798 PMCID: PMC7938317 DOI: 10.3389/fimmu.2021.624703] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/06/2021] [Indexed: 12/13/2022] Open
Abstract
Accumulating evidence suggests that the breakdown of immune tolerance plays an important role in the development of myocarditis triggered by cardiotropic microbial infections. Genetic deletion of immune checkpoint molecules that are crucial for maintaining self-tolerance causes spontaneous myocarditis in mice, and cancer treatment with immune checkpoint inhibitors can induce myocarditis in humans. These results suggest that the loss of immune tolerance results in myocarditis. The tissue microenvironment influences the local immune dysregulation in autoimmunity. Recently, tenascin-C (TN-C) has been found to play a role as a local regulator of inflammation through various molecular mechanisms. TN-C is a nonstructural extracellular matrix glycoprotein expressed in the heart during early embryonic development, as well as during tissue injury or active tissue remodeling, in a spatiotemporally restricted manner. In a mouse model of autoimmune myocarditis, TN-C was detectable before inflammatory cell infiltration and myocytolysis became histologically evident; it was strongly expressed during active inflammation and disappeared with healing. TN-C activates dendritic cells to generate pathogenic autoreactive T cells and forms an important link between innate and acquired immunity.
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Affiliation(s)
- Kazuko Tajiri
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Saori Yonebayashi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Siqi Li
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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27
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Affiliation(s)
- Siqi Li
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan
| | - Kazuko Tajiri
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan
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28
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Programmed Death-Ligand 2 Deficiency Exacerbates Experimental Autoimmune Myocarditis in Mice. Int J Mol Sci 2021; 22:ijms22031426. [PMID: 33572655 PMCID: PMC7866985 DOI: 10.3390/ijms22031426] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 12/30/2022] Open
Abstract
Programmed death ligand 2 (PD-L2) is the second ligand of programmed death 1 (PD-1) protein. In autoimmune myocarditis, the protective roles of PD-1 and its first ligand programmed death ligand 1 (PD-L1) have been well documented; however, the role of PD-L2 remains unknown. In this study, we report that PD-L2 deficiency exacerbates myocardial inflammation in mice with experimental autoimmune myocarditis (EAM). EAM was established in wild-type (WT) and PD-L2-deficient mice by immunization with murine cardiac myosin peptide. We found that PD-L2-deficient mice had more serious inflammatory infiltration in the heart and a significantly higher myocarditis severity score than WT mice. PD-L2-deficient dendritic cells (DCs) enhanced CD4+ T cell proliferation in the presence of T cell receptor and CD28 signaling. These data suggest that PD-L2 on DCs protects against autoreactive CD4+ T cell expansion and severe inflammation in mice with EAM.
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29
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Sobol I, Chen CL, Mahmood SS, Borczuk AC. Histopathologic Characterization of Myocarditis Associated With Immune Checkpoint Inhibitor Therapy. Arch Pathol Lab Med 2020; 144:1392-1396. [PMID: 32150459 DOI: 10.5858/arpa.2019-0447-oa] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Cardiac complications of immune checkpoint inhibitor therapy are rare, but reports of myocarditis are increasing. The findings have been described in case reports as lymphocytic myocarditis, but its histopathology is underreported. OBJECTIVE.— To review the histology of myocardial biopsy-proven cases of immune checkpoint-associated myocarditis and provide immunohistochemical characterization of the inflammatory infiltrate. DESIGN.— We have encountered 6 patients with biopsy-proven myocarditis in conjunction with therapy using anti-programmed death receptor-1 (PD-1)/programmed death ligand-1 (PD-L1) agents with and without cytotoxic T-lymphocyte associated protein 4 (CTLA-4) inhibitors and characterized the histopathology and immune cell profile. RESULTS.— The myocarditis was multifocal/diffuse and characterized by a predominant CD163-positive histiocytic infiltrate, with an associated CD8+ and PD-1+ T-lymphocytic infiltrate, some of which were granzyme B positive. Cardiac myocytes showed immunoreactivity for PD-L1 in areas of injury, confirmed using 2 different anti-PD-L1 clones. Four of 6 patients recovered from their cardiac injury. One patient had residual tachycardia-bradycardia syndrome and 1 patient expired. CONCLUSIONS.— The diffuse lymphohistiocytic myocarditis associated with this therapy is relatively distinctive, and this diagnosis is strongly suggested based on the histopathologic findings in the correct clinical setting.
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Affiliation(s)
- Irina Sobol
- From the Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York (Sobol, Mahmood)
| | - Carol L Chen
- the Department of Medicine, Division of Cardiology, Memorial Sloan Kettering Cancer Center, New York, New York (Chen)
| | - Syed S Mahmood
- From the Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York (Sobol, Mahmood)
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30
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Fazal M, Prentice DA, Kho LK, Fysh E. Nivolumab-associated myositis myocarditis and myasthenia and anti-striated muscle antibodies. Intern Med J 2020; 50:1003-1006. [PMID: 33306231 DOI: 10.1111/imj.14946] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/29/2020] [Accepted: 02/09/2020] [Indexed: 01/10/2023]
Abstract
An 82-year-old man was treated with neo-adjuvant nivolumab (programmed cell death protein 1 or PD-1 inhibitor) for local recurrence of melanoma developed myositis, myocarditis and a myasthenic-like syndrome with a fatal outcome. The occurrence of these three conditions may constitute a new immune checkpoint-induced syndrome. The relevance of the clinical features and the immunology is discussed. This case highlights the special role of anti-striated muscle antibodies as a predictor of mortality.
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Affiliation(s)
- Marium Fazal
- General Medicine Department, St John of God Midland Public Hospital, Perth, Western Australia, Australia
| | - David A Prentice
- General Medicine Department, St John of God Midland Public Hospital, Perth, Western Australia, Australia
| | - Lay K Kho
- Neurology Department, St John of God Midland Public Hospital, Perth, Western Australia, Australia
| | - Edward Fysh
- Respiratory Department, St John of God Midland Public Hospital, Perth, Western Australia, Australia
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31
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Hang W, Chen C, Seubert JM, Wang DW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther 2020; 5:287. [PMID: 33303763 PMCID: PMC7730152 DOI: 10.1038/s41392-020-00360-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/15/2022] Open
Abstract
Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.
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Affiliation(s)
- Weijian Hang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - John M Seubert
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta, Edmonton, Alberta, T6G 2E1, Canada.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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32
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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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33
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Gürdoğan M, Yalta K. Myocarditis associated with immune checkpoint inhibitors: Practical considerations in diagnosis and management. Anatol J Cardiol 2020; 24:68-75. [PMID: 32749254 PMCID: PMC7460679 DOI: 10.14744/anatoljcardiol.2020.79584] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) have caused radical changes in the treatment scheme of many types of cancer in the past 10 years. ICIs are specific monoclonal antibodies that increase T-cell mediated immune response against cancer cells. Despite important advances in cancer treatment, uncontrolled activation of cytotoxic T cells has brought along many autoimmune clinical side effects, especially acute myocarditis. Although the incidence of ICI-related myocarditis is about 1%, it is remarkable in terms of mortality rate reaching 46% and demonstrating the necessity of rapid diagnosis and multidisciplinary approach. The present review aimed to summarize the heterogeneous symptomatology of ICI-associated myocarditis, clinical presentation ranging from elevated asymptomatic cardiac enzyme levels to cardiogenic shock, prominent diagnostic value of cardiac magnetic resonance imaging, and current information on the effectiveness of immunosuppressants in therapy.
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Affiliation(s)
- Muhammet Gürdoğan
- Department of Cardiology, Faculty of Medicine, Trakya University; Edirne-Turkey
| | - Kenan Yalta
- Department of Cardiology, Faculty of Medicine, Trakya University; Edirne-Turkey
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34
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Lejeune M, Köse MC, Duray E, Einsele H, Beguin Y, Caers J. Bispecific, T-Cell-Recruiting Antibodies in B-Cell Malignancies. Front Immunol 2020; 11:762. [PMID: 32457743 PMCID: PMC7221185 DOI: 10.3389/fimmu.2020.00762] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/03/2020] [Indexed: 12/12/2022] Open
Abstract
Bispecific antibodies (BsAbs) are designed to recognize and bind to two different antigens or epitopes. In the last few decades, BsAbs have been developed within the context of cancer therapies and in particular for the treatment of hematologic B-cell malignancies. To date, more than one hundred different BsAb formats exist, including bispecific T-cell engagers (BiTEs), and new constructs are constantly emerging. Advances in protein engineering have enabled the creation of BsAbs with specific mechanisms of action and clinical applications. Moreover, a better understanding of resistance and evasion mechanisms, as well as advances in the protein engineering and in immunology, will help generating a greater variety of BsAbs to treat various cancer types. This review focuses on T-cell-engaging BsAbs and more precisely on the various BsAb formats currently being studied in the context of B-cell malignancies, on ongoing clinical trials and on the clinical concerns to be taken into account in the development of new BsAbs.
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Affiliation(s)
- Margaux Lejeune
- Laboratory of Hematology, GIGA I3, University of Liège, Liège, Belgium
| | - Murat Cem Köse
- Laboratory of Hematology, GIGA I3, University of Liège, Liège, Belgium
| | - Elodie Duray
- Laboratory of Hematology, GIGA I3, University of Liège, Liège, Belgium
| | - Hermann Einsele
- Department of Internal Medicine II, University of Würzburg, Würzburg, Germany
| | - Yves Beguin
- Laboratory of Hematology, GIGA I3, University of Liège, Liège, Belgium.,Department of Hematology, CHU de Liège, Liège, Belgium
| | - Jo Caers
- Laboratory of Hematology, GIGA I3, University of Liège, Liège, Belgium.,Department of Hematology, CHU de Liège, Liège, Belgium
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35
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Immune Checkpoint Inhibitor-Related Myositis: From Biology to Bedside. Int J Mol Sci 2020; 21:ijms21093054. [PMID: 32357515 PMCID: PMC7246673 DOI: 10.3390/ijms21093054] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitor (ICI)-related inflammatory diseases, including polymyositis (PM) and dermatomyositis (DM), in patients suffering from neoplastic disorders represent a medical challenge. The treatment of these conditions has taken on new urgency due to the successful and broad development of cancer-directed immunological-based therapeutic strategies. While primary and secondary PM/DM phenotypes have been pathophysiologically characterized, a rational, stepwise approach to the treatment of patients with ICI-related disease is lacking. In the absence of high-quality evidence to guide clinical judgment, the available data must be critically assessed. In this literature review, we examine partially neglected immunological and clinical findings to obtain insights into the biological profiles of ICI-related PM/DM and potential treatment options. We show that differential diagnosis is essential to stratifying patients according to prognosis and therapeutic impact. Finally, we provide a comprehensive assessment of druggable targets and suggest a stepwise patient-oriented approach for the treatment of ICI-related PM/DM.
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36
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Sun Y, Li L, Wu Y, Yang K. PD-1/PD-L1 in cardiovascular disease. Clin Chim Acta 2020; 505:26-30. [PMID: 32084380 DOI: 10.1016/j.cca.2020.02.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 01/03/2023]
Abstract
The PD-1/PD-L1 coinhibitory pathway has critical roles in the immune response and autoimmunity via the regulation of T cell activity. Excessive activity and high expression of this pathway suppresses the function of T cells and immunity. Recent research has indicated that tumour cells express high levels of PD-L1, which has an immunosuppressive effect and can result in treatment failure. Anti-PD-L1 or anti-PD-1 agents have well-established beneficial effects on mortality and quality of life in cancer patients. Based on the regulatory effects and therapeutic value of the PD-1/PD-L1 pathway in malignant disorders, we propose that it also regulates cell immunity and in CHD and atherosclerosis. Low expression level of PD-1/ PD-L1 or anti-PD-1/PD-L1 therapy accelerates the immune processes in CHD and aggravates disease according to numerous studies. A few studies have provided strong evidence that changes in the expression levels of PD-1 or PD-L1 can alter the degree of inflammation and the state of coronary plaques in atherosclerosis. In this review, we summarise the alterations of the PD-1/PD-L1 pathway and discuss its role in CHD.
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Affiliation(s)
- YunFeng Sun
- Yangtze University Health Science Center, 434020 Jingzhou City, Hubei Province, China
| | - Liang Li
- Yangtze University Health Science Center, 434020 Jingzhou City, Hubei Province, China
| | - YaWei Wu
- Affiliated Hospital of Traditional Chinese Medicine of Xinjiang Medical University, 830000 Urumqi, Xinjiang, China
| | - KePing Yang
- Yangtze University Health Science Center, 434020 Jingzhou City, Hubei Province, China; Department of Cardiology, Jingzhou Central Hospital, 434020 Jingzhou City, Hubei Province, China.
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37
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Immunomodulatory treatment of immune checkpoint inhibitor-induced myocarditis: Pathway toward precision-based therapy. Cardiovasc Pathol 2020; 47:107211. [PMID: 32268262 DOI: 10.1016/j.carpath.2020.107211] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 01/22/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)-induced myocarditis carries a poor prognosis and is not fully understood. Similar to lymphocytic myocarditis and acute cellular rejection in heart transplant, ICI-induced myocarditis requires immune suppressive strategies. We aimed to describe ICI-induced myocarditis by presenting findings of comprehensive cardiovascular evaluations and outcomes of patients following a therapeutic approach similar to autoimmune disorders or allograft transplant rejection, and to discuss the molecular basis of the benefits of immune modulation and statins in ICI-myocarditis. Three patients with ICI-induced myocarditis (2 with positive biopsies and 1 based on cardiac magnetic resonance imaging with negative biopsy) underwent a complete cardiovascular workup, including cardiac catheterization with endomyocardial biopsy. Treatment was with intravenous immunoglobulins (IVIG) and statins in all cases, with additional colchicine (2 cases) or hydroxychloroquine (1 case). Immunohistochemical analysis demonstrated varied subsets of T cells involved in the inflammatory response. Therapy with IVIG and statins led to symptom resolution and cardiac function normalization at 1-month follow-up in all patients. Cancer therapy was resumed in all patients. One patient expired 10 months after the myocarditis episode due to advanced malignancy; two patients were alive, free of heart failure symptoms and cancer progression, at 1-year follow-up, and 1 patient was rechallenged with ICI. We suggest that treatment with IVIG and statins may allow for a prompt resumption of anti-cancer therapy (including ICI) and improve outcomes.
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38
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Abstract
The role of inflammation in cardiovascular disease (CVD) is now widely accepted. Immune cells, including T cells, are influenced by inflammatory signals and contribute to the onset and progression of CVD. T cell activation is modulated by T cell co-stimulation and co-inhibition pathways. Immune checkpoint inhibitors (ICIs) targeting T cell inhibition pathways have revolutionized cancer treatment and improved survival in patients with cancer. However, ICIs might induce cardiovascular toxicity via T cell re-invigoration. With the rising use of ICIs for cancer treatment, a timely overview of the role of T cell co-stimulation and inhibition molecules in CVD is desirable. In this Review, the importance of these molecules in the pathogenesis of CVD is highlighted in preclinical studies on models of CVD such as vein graft disease, myocarditis, graft arterial disease, post-ischaemic neovascularization and atherosclerosis. This Review also discusses the therapeutic potential of targeting T cell co-stimulation and inhibition pathways to treat CVD, as well as the possible cardiovascular benefits and adverse events after treatment. Finally, the Review emphasizes that patients with cancer who are treated with ICIs should be monitored for CVD given the reported association between the use of ICIs and the risk of cardiovascular toxicity.
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39
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Hardy T, Yin M, Chavez JA, Ivanov I, Chen W, Nadasdy T, Brodsky SV. Acute fatal myocarditis after a single dose of anti-PD-1 immunotherapy, autopsy findings: a case report. Cardiovasc Pathol 2020; 46:107202. [PMID: 32062109 DOI: 10.1016/j.carpath.2020.107202] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/10/2019] [Accepted: 01/09/2020] [Indexed: 12/14/2022] Open
Abstract
Nivolumab (PD-1 inhibitor) and Ipilimumab (CTLA-34 inhibitor) are both commonly used immune checkpoint inhibitor therapies for various cancers. Various adverse events are associated with these therapies, including hepatitis, nephritis, dermatitis, and myocarditis. It is believed these adverse events occur in part because modified cellular receptors lead to enhanced CD4 and CD8 lymphoproliferation. These events usually occur after several months and rounds of treatment. Here we present a case of an 81-year-old male with recurrent renal cell carcinoma (RCC) who experienced myocarditis after only a single dose of combination therapy with Nivolumab and Ipilimumab. He presented with elevated troponins and a third-degree heart block; three days after admission he died. Histologic examination revealed a predominance of CD3 T cells (CD4 > CD8) and CD68 macrophages, with occasional CD20 B cells. C4d staining was negative in the interstitial capillaries, suggesting that antibody-mediated injury of endothelial cells did not play a significant role in the pathogenesis of this myocarditis. Additional studies ruled out an infectious etiology. Immune checkpoint inhibitors are increasingly more common, and it is important clinicians are aware patients can present with myocarditis early in the course of treatment.
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Affiliation(s)
- Tanner Hardy
- Department of Pathology and The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ming Yin
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jesus A Chavez
- Department of Pathology and The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Iouri Ivanov
- Department of Pathology and The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Wei Chen
- Department of Pathology and The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Tibor Nadasdy
- Department of Pathology and The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sergey V Brodsky
- Department of Pathology and The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Zhou YW, Zhu YJ, Wang MN, Xie Y, Chen CY, Zhang T, Xia F, Ding ZY, Liu JY. Immune Checkpoint Inhibitor-Associated Cardiotoxicity: Current Understanding on Its Mechanism, Diagnosis and Management. Front Pharmacol 2019; 10:1350. [PMID: 31849640 PMCID: PMC6897286 DOI: 10.3389/fphar.2019.01350] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/24/2019] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) that target cytotoxic T lymphocyte antigen 4, programmed cell death-1, and PD-ligand 1 have revolutionized cancer treatment, achieving unprecedented efficacy in multiple malignancies. ICIs are increasingly being used in early cancer settings and in combination with various other types of therapies, including targeted therapy, radiotherapy, and chemotherapy. However, despite the excellent therapeutic effect of ICIs, these medications typically result in a broad spectrum of toxicity reactions, termed immune-related adverse events (irAEs). Of all irAEs, cardiotoxicity, uncommon but with high mortality, has not been well recognized. Herein, based on previous published reports and current evidence, we summarize the incidence, diagnosis, clinical manifestations, underlying mechanisms, treatments, and outcomes of ICI-associated cardiotoxicity and discuss possible management strategies. A better understanding of these characteristics is critical to managing patients with ICI-associated cardiotoxicity.
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Affiliation(s)
- Yu-Wen Zhou
- Department of Biotherapy, Cancer Center, and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
| | - Ya-Juan Zhu
- Department of Biotherapy, Cancer Center, and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
| | - Man-Ni Wang
- Department of Biotherapy, Cancer Center, and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
| | - Yao Xie
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu, China
| | - Chao-Yue Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Zhang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Fan Xia
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhen-Yu Ding
- Department of Biotherapy, Cancer Center, and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
| | - Ji-Yan Liu
- Department of Biotherapy, Cancer Center, and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
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Imanaka-Yoshida K. Inflammation in myocardial disease: From myocarditis to dilated cardiomyopathy. Pathol Int 2019; 70:1-11. [PMID: 31691489 DOI: 10.1111/pin.12868] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/02/2019] [Indexed: 12/27/2022]
Abstract
Dilated cardiomyopathy (DCM) is a heterogeneous group of myocardial diseases clinically defined by the presence of left ventricular dilatation and contractile dysfunction. Among various causes of DCM, a progression from viral myocarditis to DCM has long been hypothesized. Supporting this possibility, studies by endomyocardial biopsy, the only method to obtain a definite diagnosis of myocarditis at present, have provided evidence of inflammation in the myocardium in DCM patients. A number of experimental studies have elucidated a cell-mediated autoimmune mechanism triggered by viral infection in the progression of myocarditis to DCM. In addition, the important role of inflammation in the pathogenesis of heart failure has been recognized, and many terms including myocarditis, inflammatory cardiomyopathy, and inflammatory DCM have been used for myocardial diseases associated with inflammation. This review discusses the pathophysiology of inflammation in the myocardium, and refers to diagnosis and treatment based on these concepts.
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Affiliation(s)
- Kyoko Imanaka-Yoshida
- Department of Pathology and Matrix Biology, Mie University Graduate School of Medicine, Mie, Japan.,Mie University Research Center for Matrix Biology, Mie, Japan
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Ji C, Roy MD, Golas J, Vitsky A, Ram S, Kumpf SW, Martin M, Barletta F, Meier WA, Hooper AT, Sapra P, Khan NK, Finkelstein M, Guffroy M, Buetow BS. Myocarditis in Cynomolgus Monkeys Following Treatment with Immune Checkpoint Inhibitors. Clin Cancer Res 2019; 25:4735-4748. [PMID: 31085720 DOI: 10.1158/1078-0432.ccr-18-4083] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/28/2019] [Accepted: 05/08/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Immune checkpoint inhibitors (ICI) targeting PD1, PDL1, or CTLA4 are associated with immune-related adverse events (irAE) in multiple organ systems including myocarditis. The pathogenesis and early diagnostic markers for ICI-induced myocarditis are poorly understood, and there is currently a lack of laboratory animal model to enhance our understanding. We aimed to develop such a model using cynomolgus monkeys. EXPERIMENTAL DESIGN Chinese-origin cynomolgus monkeys were dosed intravenously with vehicle or nivolumab 20 mg/kg plus ipilimumab 15 mg/kg once weekly and euthanized on day 29. RESULTS Multiple organ toxicities were observed in cynomolgus monkeys, and were characterized by loose feces, lymphadenopathy, and mononuclear cell infiltrations of varying severity in heart, colon, kidneys, liver, salivary glands, and endocrine organs. Increased proliferation of CD4+ and CD8+ T lymphocytes as well as an increase in activated T cells and central memory T cells in the blood, spleen, and lymph nodes, were observed. Transcriptomic analysis suggested increased migration and activation of T cells and increased phagocytosis and antigen presentation in the heart. Mononuclear cell infiltration in myocardium was comprised primarily of T cells, with lower numbers of macrophages and occasional B cells, and was associated with minimal cardiomyocyte degeneration as well as increases in cardiac troponin-I and NT-pro-BNP. Morphologically, cardiac lesions in our monkey model are similar to the reported ICI myocarditis in humans. CONCLUSIONS We have developed a monkey model characterized by multiple organ toxicities including myocarditis. This model may provide insight into the immune mechanisms and facilitate biomarker identification for ICI-associated irAEs.
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Affiliation(s)
- Changhua Ji
- Immunotoxicology, DSRD, Pfizer, La Jolla, California.
| | - Marc D Roy
- Investigative Toxicology, DSRD, Pfizer, Groton, Connecticut
| | - Jonathan Golas
- Oncology Targeted Therapeutics Discovery, Pearl River, New York
| | | | - Sripad Ram
- Global Pathology, DSRD, Pfizer, La Jolla, California
| | - Steven W Kumpf
- Investigative Toxicology, DSRD, Pfizer, Groton, Connecticut
| | - Matthew Martin
- Investigative Toxicology, DSRD, Pfizer, Groton, Connecticut
| | | | | | - Andrea T Hooper
- Oncology Targeted Therapeutics Discovery, Pearl River, New York
| | - Puja Sapra
- Oncology Targeted Therapeutics Discovery, Pearl River, New York
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Abstract
This year again, several breaking news were published in our field of oncodermatology, especially in the domain of immunotherapy. Many works have reported results on predictive biomarker identification. Concerning melanoma treatment, we were disappointed by the negative results of the phase III trial evaluating the IDO1 inhibitor epacadostat + pembrolizumab versus pembrolizumab. However, many promising preliminary results involving the combinations of anti-PD1 and innate immunity activators have been published. We also have a new anti-BRAF + anti-MEK combination: encorafenib + binimetinib with a good benefit/risk ratio and a particularly favorable safety profile as compared with existing similar combinations. Major steps forward were obtained for locally advanced Merkel cell carcinoma and squamous cell carcinoma with anti-PDL-1 avelumab and anti-PD1 cemiplimab respectively.
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Abstract
Immuno-oncology is a fast evolving field of cancer therapy and immune checkpoint inhibitors (ICIs) are clearly a breakthrough in this field. Cardiotoxicity with conventional anti-cancer therapies has been well studied in the past and clear guidelines for management of these side effects are available in the literature. However, cardiotoxicity with novel agents such as ICIs has been fairly under-reported and/or underestimated and we are yet to formulate clear guidelines for management of these rare side effects. In the last few years, there has been an overall increase in the number of cases of cardiotoxicity related to ICIs. In this literature review, we describe the mechanism of action of the most widely used ICIs and their related cardiotoxicities. The increase in number of case reports about the potential of cardiotoxicities with these novel agents clearly indicates the need for a new insight into the field of cardio-immuno-oncology.
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Tajiri K, Ieda M. Cardiac Complications in Immune Checkpoint Inhibition Therapy. Front Cardiovasc Med 2019; 6:3. [PMID: 30729114 PMCID: PMC6351438 DOI: 10.3389/fcvm.2019.00003] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/07/2019] [Indexed: 12/31/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have changed the treatment landscape of advanced cancers. Unfortunately, these agents can induce a wide spectrum of immune-related adverse events (irAEs) through activation of immune responses in non-target organs, including the heart. As the clinical use of ICI therapy increases rapidly, management of irAEs is becoming extremely important. The most commonly presented cardiac irAE is myocarditis. Histopathologically, T-cell (with a predominance of CD8+ cells) and macrophage infiltration in the myocardium is typically observed in ICI-associated myocarditis. Other presentations of cardiac irAEs include congestive heart failure, Takotsubo cardiomyopathy, pericardial disease, arrhythmias, and conduction disease. Although cardiac irAEs are relatively rare, they can be life-threatening. Hence, cardiologists and oncologists should be vigilant for these presentations.
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Affiliation(s)
- Kazuko Tajiri
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Michel L, Rassaf T, Totzeck M. Biomarkers for the detection of apparent and subclinical cancer therapy-related cardiotoxicity. J Thorac Dis 2018; 10:S4282-S4295. [PMID: 30701097 DOI: 10.21037/jtd.2018.08.15] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Progress in cancer therapy over the past decades improved long-term survival but increased cancer therapy-related cardiotoxicity. Many novel treatment options have been implemented with yet incompletely characterized cardiovascular side effects including heart failure, coronary artery disease, arrhythmias, valvular disease, venous thromboembolism and myocarditis. Diagnosis of potential cardiotoxic side effects is essential for an optimal treatment but remains challenging. Cardiac biomarkers troponin and brain natriuretic peptide/N-terminal proBNP (BNP/NT-proBNP) have been extensively studied in heart failure and acute coronary syndromes. Emerging evidence implicates a significant role in the detection of cardiotoxicity and guidance of therapy in cancer patients. Elevated troponin or BNP/NT-proBNP levels were associated with increased all-cause mortality in cancer patients and have been shown to predict manifest heart failure. BNP/NT-proBNP may be useful for the prediction of cancer therapy-related heart failure and response to heart failure therapy in adult and pediatric cancer patients while troponin can indicate acute myocardial infarction in patients with cancer therapy-related risk for coronary artery disease. Furthermore, troponin may be used for the identification of immune checkpoint inhibitor-related myocarditis with very high sensitivity. Finally, even D-dimer levels have been shown to improve risk stratification and diagnosis in cancer-associated venous thromboembolism. This review aims to summarize the current knowledge about biomarkers in cancer therapy-related cardiotoxicity. We also outline possible clinical recommendations for the detection and treatment of subclinical and clinically apparent cardiotoxic effects using biomarkers.
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Affiliation(s)
- Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
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Rota E, Varese P, Agosti S, Celli L, Ghiglione E, Pappalardo I, Zaccone G, Paglia A, Morelli N. Concomitant myasthenia gravis, myositis, myocarditis and polyneuropathy, induced by immune-checkpoint inhibitors: A life-threatening continuum of neuromuscular and cardiac toxicity. eNeurologicalSci 2018; 14:4-5. [PMID: 30533536 PMCID: PMC6262799 DOI: 10.1016/j.ensci.2018.11.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/17/2018] [Indexed: 11/27/2022] Open
Affiliation(s)
| | - Paola Varese
- Internal Medicine Unit, Ovada Hospital, Ovada, AL, Italy
| | - Sergio Agosti
- Cardiology Unit, San Giacomo Hospital, Novi Ligure, AL, Italy
| | | | | | | | | | - Alba Paglia
- Intensive Care Unit, San Giacomo Hospital, Novi Ligure, AL, Italy
| | - Nicola Morelli
- Neurology and Radiology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
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Bifunctional PD-1 × αCD3 × αCD33 fusion protein reverses adaptive immune escape in acute myeloid leukemia. Blood 2018; 132:2484-2494. [PMID: 30275109 DOI: 10.1182/blood-2018-05-849802] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 09/19/2018] [Indexed: 12/12/2022] Open
Abstract
The CD33-targeting bispecific T-cell engager (BiTE) AMG 330 proved to be highly efficient in mediating cytolysis of acute myeloid leukemia (AML) cells in vitro and in mouse models. Yet, T-cell activation is correlated with upregulation of programmed cell death-ligand 1 (PD-L1) and other inhibitory checkpoints on AML cells that confer adaptive immune resistance. PD-1 and PD-L1 blocking agents may counteract T-cell dysfunction, however, at the expense of broadly distributed immune-related adverse events (irAEs). We developed a bifunctional checkpoint inhibitory T cell-engaging (CiTE) antibody that combines T-cell redirection to CD33 on AML cells with locally restricted immune checkpoint blockade. This is accomplished by fusing the extracellular domain of PD-1 (PD-1ex), which naturally holds a low affinity to PD-L1, to an αCD3.αCD33 BiTE-like scaffold. By a synergistic effect of checkpoint blockade and avidity-dependent binding, the PD-1ex attachment increases T-cell activation (3.3-fold elevation of interferon-γ) and leads to efficient and highly selective cytotoxicity against CD33+PD-L1+ cell lines (50% effective concentration = 2.3-26.9 pM) as well as patient-derived AML cells (n = 8). In a murine xenograft model, the CiTE induces complete AML eradication without initial signs of irAEs as measured by body weight loss. We conclude that our molecule preferentially targets AML cells, whereas high-affinity blockers, such as clinically approved anticancer agents, also address PD-L1+ non-AML cells. By combining the high efficacy of T-cell engagers with immune checkpoint blockade in a single molecule, we expect to minimize irAEs associated with the systemic application of immune checkpoint inhibitors and suggest high therapeutic potential, particularly for patients with relapsed/ refractory AML.
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49
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Manolis AA, Manolis TA, Mikhailidis DP, Manolis AS. Cardiovascular safety of oncologic agents: a double-edged sword even in the era of targeted therapies - Part 2. Expert Opin Drug Saf 2018; 17:893-915. [PMID: 30126303 DOI: 10.1080/14740338.2018.1513489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Patients with cancer are subject to the cardiotoxic effects of cancer therapy. Improved cancer treatments lead to more cancer-survivors, who though are exposed to various forms of cardiovascular (CV) disease (CVD) as they age. Aging patients are at increased risk of developing both malignancy and CVD or they may have survived some form of CVD as a result of effective CV treatments. Furthermore, patients with CVD may develop cancer and require treatment (and vice versa), all contributing to increased morbidity and mortality. The prevalence of both malignancy and CVD will increase due to the trend toward a longer lifespan. AREAS COVERED In part 2 of this review, the discussion of the CV effects of specific oncology drugs is completed with inclusion of additional immunological agents, current hormonal and other agents. Early detection and monitoring of cardiotoxicity, use of biomarkers and other imaging and diagnostic methods and prevention and treatment options are also discussed. EXPERT OPINION As outlined in part 1 of this review, oncologists need to be aware of the CV adverse-effects of their treatments and make careful and expectant clinical decisions, especially in patients with preexisting CVD or CV risk factors. Similarly, cardiologists should consider a detailed previous history of treatment for malignant disease, including prior chemotherapy exposure, dose(s) received, and/or combined modality therapy with chest radiotherapy. Both specialists should collaborate in order to minimize the impact of these two ubiquitous diseases (cancer and CVD) and mitigate the adverse effects of treatment modalities.
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Affiliation(s)
| | | | - Dimitri P Mikhailidis
- c Department of Clinical Biochemistry , Royal Free Hospital Campus, University College London Medical School , London , UK
| | - Antonis S Manolis
- d Third Department of Cardiology , Athens University School of Medicine , Athens , Greece
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50
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Gallay L, Bourgeois-Vionnet J, Joubert B, Streichenberger N, Hot A. Muscular disorder related to immune checkpoint inhibitors: forewarned is forearmed. Neuro Oncol 2018; 20:861-862. [PMID: 29590458 DOI: 10.1093/neuonc/noy031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Laure Gallay
- Department of clinical immunology, Pavillon O, Edouard Herriot University Hospital, Hospices Civils de Lyon, Lyon, France.,INMG, CNRS UMR 5310‒INSERM U1217, Faculté Médecine et de Pharmacie, Lyon, France
| | - Julie Bourgeois-Vionnet
- French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndrome, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
| | - Nathalie Streichenberger
- INMG, CNRS UMR 5310‒INSERM U1217, Faculté Médecine et de Pharmacie, Lyon, France.,Department of Pathology, Neurology and Neurosurgery Pierre Wertheimer University Hospital, Hospices Civils de Lyon, Bron, France
| | - Arnaud Hot
- Department of clinical immunology, Pavillon O, Edouard Herriot University Hospital, Hospices Civils de Lyon, Lyon, France
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