Mitoxantrone-Induced Cardiotoxicity in Acute Myeloid Leukemia-A Velocity Vector Imaging Analysis

In-depth mechanistic analysis including high-throughput RNA sequencing in the prediction of functional and structural cardiotoxicants using hiPSC cardiomyocytes

BACKGROUND

Cardiotoxicity remains one of the most reported adverse drug reactions that lead to drug attrition during pre-clinical and clinical drug development. Drug-induced cardiotoxicity may develop as a functional change in cardiac electrophysiology (acute alteration of the mechanical function of the myocardium) and/or as a structural change, resulting in loss of viability and morphological damage to cardiac tissue.

RESEARCH DESIGN AND METHODS

Non-clinical models with better predictive value need to be established to improve cardiac safety pharmacology. To this end, high-throughput RNA sequencing (ScreenSeq) was combined with high-content imaging (HCI) and Ca2+ transience (CaT) to analyze compound-treated human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs).

RESULTS

Analysis of hiPSC-CMs treated with 33 cardiotoxicants and 9 non-cardiotoxicants of mixed therapeutic indications facilitated compound clustering by mechanism of action, scoring of pathway activities related to cardiomyocyte contractility, mitochondrial integrity, metabolic state, diverse stress responses and the prediction of cardiotoxicity risk. The combination of ScreenSeq, HCI and CaT provided a high cardiotoxicity prediction performance with 89% specificity, 91% sensitivity and 90% accuracy.

CONCLUSIONS

Overall, this study introduces mechanism-driven risk assessment approach combining structural, functional and molecular high-throughput methods for pre-clinical risk assessment of novel compounds.

The Association of Metformin With Heart Failure in Patients With Diabetes Mellitus Receiving Anthracycline Chemotherapy

Background

The prevention of heart failure (HF) is an important issue in patients treated with anthracyclines. Metformin, widely used to treat diabetes mellitus (DM), protects from anthracycline-induced cardiotoxicity in vitro and in animal models.

Objectives

The aim of our study was to test the association of metformin with the occurrence of symptomatic HF in patients with DM receiving anthracyclines.

Methods

A total of 561 patients with DM received new anthracycline therapy between 2008 and 2021 in a tertiary care center; propensity score matching was used to compare patients with or without metformin treatment. The primary outcome was new onset symptomatic HF occurring within 1 year of the initiation of anthracyclines.

Results

A total of 315 patients (65 ± 11 years of age, 33.7% male) were included. Patients with and without metformin were well matched for age, sex, type of cancer, medications, and cardiovascular risk factors. Six patients treated with metformin and 17 matched patients developed HF within 1 year of anthracycline initiation. The incidence of HF in patients treated with metformin was lower than patients without metformin within 1 year after anthracyclines (cumulative incidence: 3.6% vs 10.5%; P = 0.022; HR: 0.35; 95% CI: 0.14-0.90; P = 0.029). The use of metformin (HR: 0.71; 95% CI: 0.50-1.00; P = 0.049), was also associated with lower mortality.

Conclusions

The use of metformin was associated with a lower incidence of HF and overall mortality in patients with DM receiving anthracyclines. Our findings should be further confirmed by randomized control trials.

Cardiac Molecular Remodeling by Anticancer Drugs: Doxorubicin Affects More Metabolism While Mitoxantrone Impacts More Autophagy in Adult CD-1 Male Mice

Doxorubicin (DOX) and mitoxantrone (MTX) are classical chemotherapeutic agents used in cancer that induce similar clinical cardiotoxic effects, although it is not clear if they share similar underlying molecular mechanisms. We aimed to assess the effects of DOX and MTX on the cardiac remodeling, focusing mainly on metabolism and autophagy. Adult male CD-1 mice received pharmacologically relevant cumulative doses of DOX (18 mg/kg) and MTX (6 mg/kg). Both DOX and MTX disturbed cardiac metabolism, decreasing glycolysis, and increasing the dependency on fatty acids (FA) oxidation, namely, through decreased AMP-activated protein kinase (AMPK) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) content and decreased free carnitine (C0) and increased acetylcarnitine (C2) concentration. Additionally, DOX heavily influenced glycolysis, oxidative metabolism, and amino acids turnover by exclusively decreasing phosphofructokinase (PFKM) and electron transfer flavoprotein-ubiquinone oxidoreductase (ETFDH) content, and the concentration of several amino acids. Conversely, both drugs downregulated autophagy given by the decreased content of autophagy protein 5 (ATG5) and microtubule-associated protein light chain 3 (LC3B), with MTX having also an impact on Beclin1. These results emphasize that DOX and MTX modulate cardiac remodeling differently, despite their clinical similarities, which is of paramount importance for future treatments.

Role of advanced cardiovascular imaging in chemotherapy-induced cardiotoxicity

The development of cardiotoxicity induced by cancer treatments has emerged as a significant clinical problem, both in the short run, as it may influence drug administration in chemotherapeutic protocols, and in the long run, because it may determine adverse cardiovascular outcomes in survivors of various malignant diseases. Therefore, early detection of anticancer drug-related cardiotoxicity is an important clinical target to improve prevention of adverse effects and patient care. Today, echocardiography is the first-line cardiac imaging techniques used for identifying cardiotoxicity. Cardiac dysfunction, clinical and subclinical, is generally diagnosed by the reduction of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). However, myocardial injury detected by echocardiography is preceded by other alterations, such as myocardial perfusion and mitochondrial and metabolic dysfunction, that can only be recognized by second-level imaging techniques, like cardiac magnetic resonance (CMR) and nuclear imaging, which, using targeted radiotracers, may help to provide information on the specific mechanisms of cardiotoxicity. In this review, we focus on the current and emerging role of CMR, as a critical diagnostic tool of cardiotoxicity in the very early phase, due to its availability and because it allows the contemporary detection of functional alterations, tissue alterations (mainly performed using T1, T2 mapping with the evaluation of extracellular volume-ECV) and perfusional alteration (evaluated with rest-stress perfusion) and, in the next future, even metabolic changes. Moreover, in the subsequent future, the use of Artificial Intelligence and big data on imaging parameters (CT, CMR) and oncoming molecular imaging datasets, including differences for gender and countries, may help predict cardiovascular toxicity at its earliest stages, avoiding its progression, with precise tailoring of patients' diagnostic and therapeutic pathways.

Cardiotoxicity of Anticancer Drugs: Molecular Mechanisms and Strategies for Cardioprotection

Chemotherapy and targeted therapies have significantly improved the prognosis of oncology patients. However, these antineoplastic treatments may also induce adverse cardiovascular effects, which may lead to acute or delayed onset of cardiac dysfunction. These common cardiovascular complications, commonly referred to as cardiotoxicity, not only may require the modification, suspension, or withdrawal of life-saving antineoplastic therapies, with the risk of reducing their efficacy, but can also strongly impact the quality of life and overall survival, regardless of the oncological prognosis. The onset of cardiotoxicity may depend on the class, dose, route, and duration of administration of anticancer drugs, as well as on individual risk factors. Importantly, the cardiotoxic side effects may be reversible, if cardiac function is restored upon discontinuation of the therapy, or irreversible, characterized by injury and loss of cardiac muscle cells. Subclinical myocardial dysfunction induced by anticancer therapies may also subsequently evolve in symptomatic congestive heart failure. Hence, there is an urgent need for cardioprotective therapies to reduce the clinical and subclinical cardiotoxicity onset and progression and to limit the acute or chronic manifestation of cardiac damages. In this review, we summarize the knowledge regarding the cellular and molecular mechanisms contributing to the onset of cardiotoxicity associated with common classes of chemotherapy and targeted therapy drugs. Furthermore, we describe and discuss current and potential strategies to cope with the cardiotoxic side effects as well as cardioprotective preventive approaches that may be useful to flank anticancer therapies.

Efficacy and safety of mitoxantrone hydrochloride liposome injection in Chinese patients with advanced breast cancer: a randomized, open-label, active-controlled, single-center, phase II clinical trial

Purpose. This trial aimed to evaluate the efficacy and safety of mitoxantrone hydrochloride liposome injection (Lipo-MIT) in advanced breast cancer (ABC). Methods. In this randomized, open-label, active-controlled, single-center, phase II clinical trial, eligible patients were randomized in a ratio of 1:1 to receive Lipo-MIT or mitoxantrone hydrochloride injection (MIT) intravenously. The primary endpoint was objective response rate (ORR). The secondary endpoints were disease control rate (DCR), progression-free survival (PFS), and safety outcomes. Results. Sixty patients were randomized to receive Lipo-MIT or MIT. The ORR was 13.3% (95% confidence interval (CI): 3.8–30.7%) for Lipo-MIT and 6.7% (95% CI: 0.8–22.1%) for MIT. The DCR was 50% (95% CI: 31.3–68.7%) with Lipo-MIT vs. 30% (95% CI: 14.7–49.4%) with MIT. The median PFS was 1.92 months (95% CI: 1.75–3.61) for Lipo-MIT and 1.85 months (95% CI: 1.75–2.02) for MIT. The most common toxicity was myelosuppression. Lipo-MIT resulted in an incidence of 86.7% of leukopenia and 80.0% of neutropenia, which was marginally superior to MIT (96.7% and 96.7%, respectively). Lipo-MIT showed a lower incidence of cardiovascular events (13.3% vs. 20.0%) and increased cardiac troponin T (3.3% vs. 36.7%); but higher incidence of anemia (76.7% vs. 46.7%), skin hyperpigmentation (66.7% vs. 3.3%), and fever (23.3% vs. 10.0%) than MIT. Conclusions The clinical benefit parameters of Lipo-MIT and MIT were comparable. Lipo-MIT provided a different toxicity profile, which might be associated with the altered distribution of the drug. Additional study is needed to elucidate the potential benefit of Lipo-MIT in ABC. Clinical trial registration. This study is registered with ClinicalTrials.gov (No. NCT02596373) on Nov 4, 2015.

The role of the Tei index in assessing for cardiotoxicity from anthracycline chemotherapy: a systematic review

Background

Anthracycline agents are known to be effective in treating tumors and hematological malignancies. Although these agents improve survival, their use is associated with cardiotoxic effects, which most commonly manifests as left ventricular systolic dysfunction (LVSD). As such, guidelines recommend the periodic assessment of left ventricular ejection fraction (LVEF). However, as diastolic dysfunction likely proceeds systolic impairment in this setting, the role of Tei index may offer additional benefit in detecting subclinical LVSD.

Methods

We conducted a systematic review to investigate the evidence for the use of Tei index in assessing subclinical cardiotoxicity in patients receiving anticancer agents. A search of Medline and EMBASE was performed and relevant studies were reviewed and narratively synthesized.

Results

A total of 13 studies were included with a total of 800 patients (mean age range 46–62 years, percentage of male participants ranged from 0–86.9%). An increase in Tei index was observed in 11 studies, which suggested a decline in cardiac function following chemotherapy. Out of these, six studies indicated that the Tei index is a useful parameter in predicting cardiotoxic LVSD. Furthermore, five studies indicated Tei index to be superior to LVEF in detecting subclinical cardiotoxicity.

Conclusions

Though there are some studies that suggest that Tei index may be a useful indicator in assessing subclinical anthracycline-related cardiotoxicity, the findings are inconsistent and so more studies are needed before the evaluation of Tei index is performed routinely in patients receiving chemotherapy.

Role of myocardial strain imaging in surveillance and management of cancer therapeutics-related cardiac dysfunction: A systematic review

Transthoracic echocardiography is the primary cardiac imaging modality for the detection of Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD) through evaluation of serial changes in left ventricular ejection fraction (LVEF). However, LVEF assessment by standard methods including 3D Echo has important limitations including the fact that reduction in LVEF occurs late in the process of CTRCD. In contrast, by detecting early myocardial change, myocardial strain or deformation imaging has evolved to be a preferred parameter for detecting CTRCD. Peak systolic global longitudinal strain (GLS) by speckle-tracking echocardiography (STE) has become an important prechemotherapy parameter that can independently predict subsequent adverse cardiac events as these abnormalities typically precede reduction in LVEF. While an absolute GLS measurement may be informative, a 10%-15% early reduction in GLS by STE appears to be the most useful prognosticator for cardiotoxicity while on therapy. In this paper, we present a current systematic literature review of application of myocardial strain imaging in cancer patients performed following PRISMA guidelines using electronic databases from MEDLINE, Embase, and SCOPUS Library from their inception until June 11th 2020. This review demonstrates the incremental value of myocardial deformation imaging over traditional LVEF in detection and its clinical implication in management of CTRCD.

Assessment of Prognostic Value of Left Ventricular Global Longitudinal Strain for Early Prediction of Chemotherapy-Induced Cardiotoxicity: A Systematic Review and Meta-analysis

Importance

Echocardiographic left ventricular global longitudinal strain (GLS) detects early subclinical ventricular dysfunction and can be used in patients receiving potentially cardiotoxic chemotherapy. A meta-analysis of the prognostic value of GLS for cancer therapy-related cardiac dysfunction (CTRCD) has not been performed, to our knowledge.

Objective

To explore the prognostic value of GLS for the prediction of CTRCD.

Data Sources

Systematic search of the MEDLINE, Embase, Scopus, and the Cochrane Library databases from database inception to June 1, 2018.

Study Selection

Cohort studies assessing the prognostic or discriminatory performance of GLS before or during chemotherapy for subsequent CTRCD.

Data Extraction and Synthesis

Random-effects meta-analysis and hierarchical summary receiver operating characteristic curves (HSROCs) were used to summarize the prognostic and discriminatory performance of different GLS indices. Publication bias was assessed using the Egger test, and meta-regression was performed to assess sources of heterogeneity.

Main Outcomes and Measures

The primary outcome was CTRCD, defined as a clinically significant change in left ventricular ejection fraction with or without new-onset heart failure symptoms.

Results

Analysis included 21 studies comprising 1782 patients with cancer, including breast cancer, hematologic malignancies, or sarcomas, treated with anthracyclines with or without trastuzumab. The incidence of CTRCD ranged from 9.3% to 43.8% over a mean follow-up of 4.2 to 23.0 months (pooled incidence, 21.0%). For active treatment absolute GLS (9 studies), the high-risk cutoff values ranged from -21.0% to -13.8%, with worse GLS associated with a higher CTRCD risk (odds ratio, 12.27; 95% CI, 7.73-19.47; area under the HSROC, 0.86; 95% CI, 0.83-0.89). For relative changes vs a baseline value (9 studies), cutoff values ranged from 2.3% to 15.9%, with a greater decrease linked to a 16-fold higher risk of CTRCD (odds ratio, 15.82; 95% CI, 5.84-42.85; area under the HSROC, 0.86; 95% CI, 0.83-0.89). Both indices showed significant publication bias. Meta-regression identified differences in sample size and CTRCD definition but not GLS cutoff value as significant sources of interstudy heterogeneity.

Conclusions and Relevance

In this meta-analysis, measurement of GLS after initiation of potentially cardiotoxic chemotherapy with anthracyclines with or without trastuzumab had good prognostic performance for subsequent CTRCD. However, risk of bias in the original studies, publication bias, and limited data on the incremental value of GLS and its optimal cutoff values highlight the need for larger prospective multicenter studies.

Study on the precise mechanism of Mitoxantrone-induced Jurkat cell apoptosis using surface enhanced Raman scattering

Mitoxantrone (MTX), one representative of anthraquinone ring anticancer drugs, reveals excellent anticancer effects in acute leukemia. Though current studies have shown that MTX-induced acute leukemia cell apoptosis is implemented by inserting into DNA, and then leading to DNA breakage and the subsequent transcription termination, but the specific location information of MTX embedded in DNA remains unknown. In this study, combining surface enhanced Raman scattering (SERS) and principal component analysis (PCA), we achieve the biochemical changes of MTX-induced Jurkat cell apoptosis and the location information of MTX embedded in DNA. In contrast, we also present the corresponding result of Daunorubicin (DNR)-induced Jurkat cell apoptosis. It is found that the location of MTX embedded in DNA of Jurkat cell is different from DNR, in which the action site of MTX is mainly implemented by blocking and destroying AT base pairs while DNR is performed by embedding and destroying GC base pairs and then the base A. Clearly, this achieved information is very useful for the designing and modification of anthraquinone ring anticancer drugs.

Assessment of Cardiotoxicity of Cancer Chemotherapy: The Value of Cardiac MR Imaging

Chemotherapy is associated with cardiovascular injury, including the development of a cardiomyopathy and vascular remodeling. Cardiac magnetic resonance (CMR) is sensitive to detect not only established morphologic and functional abnormalities but also early, potentially reversible, signs of myocardial injury. It robustly detects and quantifies myocardial edema, inflammation, and focal fibrosis, as well as interstitial fibrosis and vascular remodeling. These capabilities support the role of CMR as an excellent tool for evaluating cardiotoxicity. Novel CMR markers may even enhance patient management by facilitating the early detection of reversible myocardial tissue remodeling before classic morphologic and functional changes appear.

Observation of clinical efficacy and toxic and side effects of pirarubicin combined with cytarabine on acute myeloid leukemia

Efficacy and toxic and side effects of pirarubicin combined with cytarabine and mitoxantrone combined with cytarabine on the treatment of initially treated acute myeloid leukemia (AML) were compared. A retrospective analysis was performed on the medical records of 76 AML patients who were initially treated in Weifang People's Hospital. Among them, 36 patients (observation group) were treated with pirarubicin combined with cytarabine, and 40 patients (control group) were treated with mitoxantrone combined with cytarabine. The efficacy and toxic and side effects on patients in the two groups were observed. There was no statistically significant difference in the complete response (CR) rate, partial response (PR) rate and overall response (OR) rate of patients between the two groups (P>0.05). Patients in the observation group had significantly lower incidence of cardiotoxicity and alopecia than those in the control group (P<0.05). Patients in the observation group had lower incidence of bone marrow depression (BMD) at grade IV than those in the control group (P<0.05). The median progression-free survival time of patients was 14.5 months in the observation group and 18 months in the control group. The progression-free survival rate of patients was 36.11% in the observation group and 40.00% in the control group, with no difference between the two groups (P>0.05). The median survival time of patients was 22.5 months in the observation group and 24.5 months in the control group. The overall survival (OS) rate of patients was 44.44% in the observation group and 47.50% in the control group, with no difference between the two groups (P>0.05). Both pirarubicin combined with cytarabine and mitoxantrone combined with cytarabine have satisfactory efficacy on initially treated AML. Compared to the latter, the former has lower toxic and side effects.

Elderly do benefit from induction chemotherapy: High dose mitoxantrone-based ("5 + 1") induction chemotherapy regimen in newly diagnosed acute myeloid leukemia

An intensive "5 + 1" regimen, which included bolus high dose cytarabine (HiDAC) at 3 g/m² once daily over 3 hours on days 1-5 and high dose mitoxantrone (HDM) 80 mg/m² on day 2, was evaluated in 101 consecutively treated newly diagnosed acute myeloid leukemia (AML) patients at a single center since 2009. The median age was 65 (range 18-90) years. The 4 and 8-week mortality in our cohort was 3/101 (2.9%) and 7/99 (7%), respectively. The overall response (complete remission [CR] + CRi) was 76.2% (77/101). The median overall survival (OS) stratified by age group <60, 60-69 and ≥70 years were 56, 31 and 9 months respectively (log-rank, P = 0.02). 51.7% (45/84) of patients with intermediate/adverse risk category proceeded to allogeneic stem cell transplants. Among these 84 patients, the percentage of patients able to proceed to transplant in age groups <60, 60-69, and ≥ 70 years were 75% (18/24), 60.7% (17/28), and 31.2% (10/32), respectively. In conclusion, HDM-based chemotherapy regimen produces high CR rates, is well tolerated and more patients can undergo curative postremission therapy including stem cell transplant.

Influence of PARP-1 inhibition in the cardiotoxicity of the topoisomerase 2 inhibitors doxorubicin and mitoxantrone

Doxorubicin (DOX) and Mitoxantrone (MTX) are very effective drugs for a range of tumors despite being highly cardiotoxic. DNA topoisomerase 2 beta (Top2ß) was revealed as key mediator of DOX-induced cardiotoxicity, although ROS generation is also an important mechanism. Oxidative stress is also an important issue in MTX-induced cardiotoxicity that is manifested by mitochondrial dysfunction. Studies have demonstrated the relationship between PARP-1 overactivation and cell viability in DOX-treated cardiomyocytes. In reference of MTX, data regarding PARP-1 overactivation as the mechanism responsible for cardiotoxicity is difficult to find. The aim of this study was to evaluate the influence of PARP-1 inhibitor DPQ on DOX- and MTX-mediated cardiotoxicity. Cells were exposed for 24 h to DOX or MTX in the presence or absence of DPQ. Viability, apoptosis, and genotoxicity assays were carried out. Immunofluorescence of phosphorylated histone H2AX was analyzed in H9c2 cells and cardiomyocytes from neonatal rats. Results demonstrated that DPQ co-treatment increases DOX-induced apoptosis in H9c2 cells. DPQ also prevents DOX and MTX-ROS generation in part by increasing SOD and CAT activities. Furthermore, DPQ co-treatment increased the generation of DNA strand breaks by DOX and MTX whilst also inducing phosphorylation of H2AX, MRE11, and ATM in H9c2 cells. Our results demonstrated that as well as increasing DNA damage and inducing apoptotic cell death, DPQ enhances DOX- and MTX-mediated cytotoxicity in H9c2.