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Gergely TG, Drobni ZD, Kallikourdis M, Zhu H, Meijers WC, Neilan TG, Rassaf T, Ferdinandy P, Varga ZV. Immune checkpoints in cardiac physiology and pathology: therapeutic targets for heart failure. Nat Rev Cardiol 2024; 21:443-462. [PMID: 38279046 DOI: 10.1038/s41569-023-00986-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/28/2024]
Abstract
Immune checkpoint molecules are physiological regulators of the adaptive immune response. Immune checkpoint inhibitors (ICIs), such as monoclonal antibodies targeting programmed cell death protein 1 or cytotoxic T lymphocyte-associated protein 4, have revolutionized cancer treatment and their clinical use is increasing. However, ICIs can cause various immune-related adverse events, including acute and chronic cardiotoxicity. Of these cardiovascular complications, ICI-induced acute fulminant myocarditis is the most studied, although emerging clinical and preclinical data are uncovering the importance of other ICI-related chronic cardiovascular complications, such as accelerated atherosclerosis and non-myocarditis-related heart failure. These complications could be more difficult to diagnose, given that they might only be present alongside other comorbidities. The occurrence of these complications suggests a potential role of immune checkpoint molecules in maintaining cardiovascular homeostasis, and disruption of physiological immune checkpoint signalling might thus lead to cardiac pathologies, including heart failure. Although inflammation is a long-known contributor to the development of heart failure, the therapeutic targeting of pro-inflammatory pathways has not been successful thus far. The increasingly recognized role of immune checkpoint molecules in the failing heart highlights their potential use as immunotherapeutic targets for heart failure. In this Review, we summarize the available data on ICI-induced cardiac dysfunction and heart failure, and discuss how immune checkpoint signalling is altered in the failing heart. Furthermore, we describe how pharmacological targeting of immune checkpoints could be used to treat heart failure.
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Affiliation(s)
- Tamás G Gergely
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Budapest, Hungary
| | - Zsófia D Drobni
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marinos Kallikourdis
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Adaptive Immunity Lab, Humanitas Research Hospital IRCCS, Milan, Italy
| | - Han Zhu
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wouter C Meijers
- Erasmus MC, Cardiovascular Institute, Thorax Center, Department of Cardiology, Rotterdam, The Netherlands
| | - Tomas G Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Zoltán V Varga
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.
- HCEMM-SU Cardiometabolic Immunology Research Group, Budapest, Hungary.
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Budapest, Hungary.
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2
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Shalata W, Steckbeck R, Abu Salman A, Abu Saleh O, Abu Jama A, Attal ZG, Shalata S, Alnsasra H, Yakobson A. Perimyocarditis Associated with Immune Checkpoint Inhibitors: A Case Report and Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:224. [PMID: 38399513 PMCID: PMC10890382 DOI: 10.3390/medicina60020224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Patient prognoses have been significantly enhanced by immune checkpoint inhibitors (ICIs), altering the standard of care in cancer treatment. These novel antibodies have become a mainstay of care for metastatic non-small-cell lung cancer (mNSCLC) patients. Several types of adverse events related to ICIs have been identified and documented as a result of the launch of these innovative medicines. We present here a 74-year-old female patient with a stage IV lung adenocarcinoma, treated with nivolumab plus ipilimumab, who developed perimyocarditis two weeks after receiving the third cycle of immune checkpoint inhibitor therapy. The patient was diagnosed using troponin levels, computed tomography (CT) angiography, and echocardiography. After hospitalization, her cardiac condition was successfully resolved with corticosteroids, colchicine, and symptomatic treatment. To the best of our knowledge, this is one of the rarest cases to be reported of perimyocarditis as a toxicity of immunotherapy in a patient treated for adenocarcinoma of the lung.
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Affiliation(s)
- Walid Shalata
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Rachel Steckbeck
- Medical School for International Health and Sciences, Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Amjad Abu Salman
- Cardiology Department, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Omar Abu Saleh
- Department of Dermatology and Venereology, Emek Medical Centre, Afula 18341, Israel
| | - Ashraf Abu Jama
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Zoé Gabrielle Attal
- Medical School for International Health and Sciences, Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Sondos Shalata
- Nutrition Unit, Galilee Medical Center, Nahariya 22000, Israel
| | - Hilmi Alnsasra
- Cardiology Department, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Alexander Yakobson
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
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3
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Tini G, Arcari L, Mistrulli R, Follesa F, Cianca A, Sclafani M, Tocci G, Spallarossa P, Battistoni A, Cacciotti L, Musumeci B, Barbato E. A contemporary update on cancer and takotsubo syndrome. Front Cardiovasc Med 2024; 10:1301383. [PMID: 38259302 PMCID: PMC10800806 DOI: 10.3389/fcvm.2023.1301383] [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: 09/24/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Takotsubo syndrome (TTS) is characterized by a transient left ventricular systolic dysfunction, burdened by significant acute and long-term mortality and morbidity. The prognosis of TTS, especially in the long-term, is influenced by both non-cardiovascular (non-CV) and CV comorbidities, among which cancer is one of the most common. The presence of a malignancy is proven to be associated with higher mortality in TTS. Moreover, a number of anticancer treatments has been reported to possibly cause TTS as a form of cardiotoxicity, even though clearcut associations are lacking. The aim of this narrative review is to sum up contemporary knowledge on the association of cancer and TTS, addressing unmet needs and practical implications. The importance of a close collaboration between cardiologists and oncologists is herein highlighted, both to allow an adequate management of the acute TTS phase, and to actively and safely return to the oncologic management once the acute setting is resolved.
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Affiliation(s)
- Giacomo Tini
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Luca Arcari
- Cardiology Unit, Madre Giuseppina Vannini Hospital, Rome, Italy
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Raffaella Mistrulli
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Federico Follesa
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Cianca
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Matteo Sclafani
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giuliano Tocci
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino—IRCCS Italian Cardiology Network, Genova, Italy
| | - Allegra Battistoni
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Luca Cacciotti
- Cardiology Unit, Madre Giuseppina Vannini Hospital, Rome, Italy
| | - Beatrice Musumeci
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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4
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Chitsazan M, Amin A, Ladel L, Baig A, Chitsazan M. Cardiovascular Toxicity Associated With Immune Checkpoint Inhibitor Therapy: A Comprehensive Review. Crit Pathw Cardiol 2023; 22:69-82. [PMID: 37363862 DOI: 10.1097/hpc.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Immune checkpoint inhibitors (ICIs), a significant breakthrough treatment of cancer, exert their function through enhancing the immune system's ability to recognize and attack cancer cells. However, these revolutionary cancer treatments have been associated with a range of immune-related adverse effects, including cardiovascular toxicity. The most commonly reported cardiovascular toxicities associated with ICIs are myocarditis, pericarditis, arrhythmias, and vasculitis. These cardiovascular manifestations are often severe and can lead to life-threatening complications. Therefore, prompt identification and management of these toxicities is critical, and a multidisciplinary teamwork by cardiologists and oncologists are required to ensure optimal patient outcomes. In this review, we summarize the current knowledge on the mechanisms underlying ICI-associated cardiovascular toxicity, clinical presentations of these toxicities, potential risk factors, diagnosis, management, and surveillance strategies during ICI therapy. While ICIs have already transformed cancer treatment, further research is needed to better understand and manage their immune-related cardiovascular effects, and possibly, to identify biomarkers which can predict the occurrence of these cardiovascular complications.
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Affiliation(s)
| | - Ahmad Amin
- Medstar Union Memorial Hospital, Baltimore, MD
| | - Luisa Ladel
- From the Department of Medicine, Norwalk Hospital, Norwalk, CT
| | - Alyza Baig
- From the Department of Medicine, Norwalk Hospital, Norwalk, CT
| | - Mitra Chitsazan
- Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Somers-Edgar TJ, Shah J, Kueh A, Kasargod Prabhakar C. Triptan-induced takotsubo syndrome: a case report. Eur Heart J Case Rep 2023; 7:ytad221. [PMID: 37575544 PMCID: PMC10413313 DOI: 10.1093/ehjcr/ytad221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/17/2022] [Accepted: 04/24/2023] [Indexed: 08/15/2023]
Abstract
Background Takotsubo syndrome (TS) is a clinical condition mimicking acute coronary syndrome characterized by reversible acute systolic dysfunction. TS is typically associated with a catecholaminergic surge resulting from physical or emotional stress while some pharmacologic agents may act as a trigger. Case summary Here, we report a case of TS secondary to rizatriptan, used for treatment of acute migraine. A 67-year-old woman with a history of dyslipidemia, type II diabetes, and migraine was admitted with chest heaviness shortly after taking rizatriptan for migraine. Deepening T wave inversion was seen in multiple territories on electrocardiogram and hs-troponin T was elevated. Cardiac imaging including echocardiogram coronary angiography and cardiac magnetic resonance imaging was consistent with a diagnosis of TS. Discussion In this case, there was no emotional trigger for TS described. Given the compelling temporal correlation between the onset of typical chest pain and medication use, a diagnosis of TS secondary to rizatriptan was made.
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Affiliation(s)
- Tiffany Joy Somers-Edgar
- Green Lane Cardiovascular Services, Auckland City Hospital; Te Whatu Ora, Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Jignesh Shah
- Green Lane Cardiovascular Services, Auckland City Hospital; Te Whatu Ora, Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Anthony Kueh
- Green Lane Cardiovascular Services, Auckland City Hospital; Te Whatu Ora, Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Chethan Kasargod Prabhakar
- Green Lane Cardiovascular Services, Auckland City Hospital; Te Whatu Ora, Health New Zealand, Te Toka Tumai, Auckland, New Zealand
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Cobarro L, Valbuena-López S, Contreras C, Ugueto C, Ruiz-Gutiérrez I, Peña-López J, Ruiz-Giménez L, López-Fernández T. Immune Checkpoint Inhibitor-Related Stress Cardiomyopathy: Differential Diagnosis and Key Role of Cardiac Imaging. JACC Case Rep 2023; 16:101881. [PMID: 37396332 PMCID: PMC10313486 DOI: 10.1016/j.jaccas.2023.101881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 07/04/2023]
Abstract
A 76-year-old man with stage IV urothelial carcinoma who was receiving atezolizumab presented with dyspnea, elevated cardiac biomarkers, new negative T waves, and left ventricular apical akinesia. Coronary angiography results were normal. Immune checkpoint inhibitor-related myocarditis was suspected, and high-dose corticosteroid treatment was started. Cardiac magnetic resonance showed apical edema, suggesting stress cardiomyopathy. (Level of Difficulty: Beginner.).
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Affiliation(s)
- Lucía Cobarro
- Department of Cardiology, La Paz University Hospital, Madrid, Spain
| | | | | | - Clara Ugueto
- Department of Cardiology, La Paz University Hospital, Madrid, Spain
| | | | - Jesús Peña-López
- Department of Oncology, La Paz University Hospital, Madrid, Spain
| | | | - Teresa López-Fernández
- Department of Cardiology, La Paz University Hospital, Madrid, Spain
- Cardio-Oncology Unit, La Paz University Hospital, Madrid, Spain
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Khan WJ, Asif M, Chaudhry HS, Aslam S, Nadeem I. Pembrolizumab-Induced Broken Heart Syndrome, Pneumonitis, and Hypophysitis Occurring Concurrently; A Deadly Triad. J Community Hosp Intern Med Perspect 2023; 13:88-90. [PMID: 37877053 PMCID: PMC10593175 DOI: 10.55729/2000-9666.1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/21/2023] [Accepted: 02/01/2023] [Indexed: 10/26/2023] Open
Abstract
Immune checkpoint inhibitors are novel medications used to treat a wide range of solid organ tumors and work by stimulating the cellular immune response. With their increasing use, more and more multiorgan side effects are reported in the literature. Prompt recognition of these findings is vital for the safe clinical use of these agents. Most side effects are immune-mediated injury, and the treatment involves stopping the ICI drug and systemic steroids. We report a case of a 72-year-old female treated with pembrolizumab monotherapy for non-small cell lung cancer. She presented for dyspnea and generalized weakness after the second session of pembrolizumab. She was found to have a triad of Takotsubo cardiomyopathy, hypophysitis, and pneumonitis. The patient was discharged home on steroids and heart failure treatment with the discontinuation of further sessions of pembrolizumab.
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Affiliation(s)
- Wahab J. Khan
- University of South Dakota Sanford School of Medicine, Sioux Falls, SD,
USA
| | - Muhammad Asif
- University of South Dakota Sanford School of Medicine, Sioux Falls, SD,
USA
| | - Hammad S. Chaudhry
- University of South Dakota Sanford School of Medicine, Sioux Falls, SD,
USA
| | - Sadia Aslam
- Avera McKennan Hospital and University Health Center, Sioux Falls, SD,
USA
| | - Ifrah Nadeem
- University of South Dakota Sanford School of Medicine, Sioux Falls, SD,
USA
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8
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Trontzas IP, Vathiotis IA, Kyriakoulis KG, Sofianidi A, Spyropoulou Z, Charpidou A, Kotteas EA, Syrigos KN. Takotsubo Cardiomyopathy in Cancer Patients Treated with Immune Checkpoint Inhibitors: A Systematic Review and Meta-Summary of Included Cases. Cancers (Basel) 2023; 15:cancers15092637. [PMID: 37174104 PMCID: PMC10177389 DOI: 10.3390/cancers15092637] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/29/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND There are emerging reports of Takotsubo syndrome (TTS) in cancer patients treated with immune checkpoint inhibitors (ICIs); however, the association of the two remains uncertain. METHODS A systematic literature review was performed in the PubMed database and web sources (Google Scholar) according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. Case reports/series or studies including cancer patients treated with ICIs and presenting with TTS were considered. RESULTS Seventeen cases were included in the systematic review. Most patients were males (59%) with median age of 70 years (30-83). Most common tumor types were lung cancer (35%) and melanoma (29%). Most patients were on first-line immunotherapy (35%) and after the first cycle (54%) of treatment. The median time on immunotherapy at the time of TTS presentation was 77 days (1-450). The most used agents were pembrolizumab and the combination of nivolumab-ipilimumab (35%, respectively). Potential stressors were recognized in 12 cases (80%). Six patients (35%) presented with concurrent cardiac complications. Corticosteroids were used in the management of eight patients (50%). Fifteen patients (88%) recovered from TTS, two patients (12%) relapsed, and one patient died. Immunotherapy was reintroduced in five cases (50%). CONCLUSION TTS may be associated with immunotherapy for cancer. Physicians should be alert for TTS diagnosis in any patient with myocardial infarction-like presentation under treatment with ICIs.
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Affiliation(s)
- Ioannis P Trontzas
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06519, USA
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Ioannis A Vathiotis
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06519, USA
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Konstantinos G Kyriakoulis
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Amalia Sofianidi
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Zoi Spyropoulou
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Andriani Charpidou
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Elias A Kotteas
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Konstantinos N Syrigos
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece
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9
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Song W, Zheng Y, Dong M, Zhong L, Bazoukis G, Perone F, Li G, Ng CF, Baranchuk A, Tse G, Liu T. Electrocardiographic Features of Immune Checkpoint Inhibitor-Associated Myocarditis. Curr Probl Cardiol 2023; 48:101478. [PMID: 36336121 DOI: 10.1016/j.cpcardiol.2022.101478] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are associated with immune-related adverse events including myocarditis, whilst improving cancer-related outcomes. There is thus a clinical need to identify electrocardiographic manifestations of ICI-related myocarditis to guide clinical management. PubMed was searched for clinical studies and case reports describing electrocardiographic changes in patients with ICI-related myocarditis. A total of 6 clinical studies and 79 case reports were included. This revealed a range of presentations for patients on ICIs, including supraventricular arrhythmias, ventricular arrhythmias and heart block, and new changes of ST-T segment unrelated to coronary artery disease, ST-segment elevation or depression and T-wave abnormalities. Several patients showed low voltages in multiple leads and new onset Q-wave development. Patients with ICI-related myocarditis may develop new arrhythmia and ST-T changes, and infrequently low voltages in multiple leads.
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Affiliation(s)
- Wenhua Song
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yi Zheng
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Mei Dong
- Department of Cardiology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai Shandong, China
| | - Lin Zhong
- Department of Cardiology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai Shandong, China
| | - George Bazoukis
- Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus; Department of Basic and Clinical Sciences, University of Nicosia Medical School, 2414, Nicosia, Cyprus
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic "Villa delle Magnolie", Castel Morrone, Caserta, Italy
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Chi Fai Ng
- SH Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Science, Center, Queen's University, Kingston, Ontario, Canada
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China; Epidemiology Research Unit, Cardiovascular Analytics Group, Hong Kong, China; Kent and Medway Medical School, University of Kent and Canterbury Christ Church University, Canterbury, Kent, UK; School of Nursing and Health Studies, Hong Kong, Metropolitan University, Hong Kong, China.
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.
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10
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Airò G, Maffezzoli M, Lazzarin A, Bianconcini M, Greco A, Buti S, Leonetti A. Takotsubo syndrome in a patient with metastatic renal cell carcinoma treated with pembrolizumab plus axitinib. Immunotherapy 2022; 14:1297-1305. [DOI: 10.2217/imt-2022-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report the case of a patient with metastatic renal cell carcinoma who developed Takotsubo syndrome (TTS) 6 days after starting pembrolizumab plus axitinib as first-line treatment. Coronary angiogram was negative for obstructive coronary artery disease and echocardiogram revealed a depressed left ventricular ejection fraction with apical akinesis. Axitinib was discontinued and myocardial contractile function fully recovered 23 days after the initial presentation. The treatment was safely resumed and granted a partial response of disease. A literature review regarding TTS in patients receiving VEGFR tyrosine kinase inhibitors and/or immune checkpoint inhibitors was performed. TTS is reported as a rare adverse event and the possible causal relationship between TTS and antineoplastic therapy is still unclear. Further research is warranted to better understand cardiotoxicity mechanisms and their management.
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Affiliation(s)
- Giulia Airò
- Medical Oncology Unit, University Hospital of Parma, Parma, 43126, Italy
| | - Michele Maffezzoli
- Medical Oncology Unit, University Hospital of Parma, Parma, 43126, Italy
| | | | | | - Alessandro Greco
- Cardiology Unit, University Hospital of Parma, Parma, 43126, Italy
| | - Sebastiano Buti
- Medical Oncology Unit, University Hospital of Parma, Parma, 43126, Italy
- Department of Medicine & Surgery, University of Parma, Parma, 43126, Italy
| | - Alessandro Leonetti
- Medical Oncology Unit, University Hospital of Parma, Parma, 43126, Italy
- Department of Medicine & Surgery, University of Parma, Parma, 43126, Italy
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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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Kushnareva E, Kushnarev V, Artemyeva A, Mitrofanova L, Moiseeva O. Myocardial PD-L1 Expression in Patients With Ischemic and Non-ischemic Heart Failure. Front Cardiovasc Med 2022; 8:759972. [PMID: 35096992 PMCID: PMC8792535 DOI: 10.3389/fcvm.2021.759972] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/17/2021] [Indexed: 12/19/2022] Open
Abstract
Objective: Immune checkpoints inhibitors are promising and wide-spread agents in anti-cancer therapy. However, despite their efficacy, these agents could cause cardiotoxicity, a rare but life-threatening event. In addition, there are still no well-described predictive factors for the development of immune-related adverse events and information on high risk groups. According to known experimental studies we hypothesized that cardiovascular diseases may increase myocardial PD-L1 expression, which could be an extra target for Checkpoint inhibitors and a potential basis for complications development. Methods: We studied patterns of myocardial PD-L1 expression in non-cancer-related cardiovascular diseases, particularly ischemic heart disease (n = 12) and dilated cardiomyopathy (n = 7), compared to patients without known cardiovascular diseases (n = 10) using mouse monoclonal anti-PD-L1 antibody (clone 22C3, 1:50, Dako). Correlation between immunohistochemical data and echocardiographic parameters was assessed. Statistical analyses were performed using R Statistical Software—R studio version 1.3.1093. Results: In the myocardium of cardiac patients, we found membranous, cytoplasmic, and endothelial expression of PD-L1 compared to control group. In samples from patients with a history of myocardial infarction, PD-L1 membrane and endothelial expression was more prominent and frequent, and cytoplasmic and intercalated discs staining was more localized. In contrast, samples from patients with dilated cardiomyopathy displayed very faint endothelial staining, negative membrane staining, and more diffuse PD-L1 expression in the cytoplasm and intercalated discs. In samples from the non-cardiac patients, no convincing PD-L1 expression was observed. Moreover, we discovered a significant negative correlation between PD-L1 expression level and left ventricular ejection fraction and a positive correlation between PD-L1 expression level and left ventricular end-diastolic volume. Conclusions: The present findings lay the groundwork for future experimental and clinical studies of the role of the PD-1/PD-L1 pathway in cardiovascular diseases. Further studies are required to find patients at potentially high risk of cardiovascular adverse events associated with immune checkpoint inhibitors therapy.
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Affiliation(s)
- Ekaterina Kushnareva
- Personalized Medicine Centre, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - Vladimir Kushnarev
- Personalized Medicine Centre, Almazov National Medical Research Centre, Saint Petersburg, Russia.,N. N. Petrov National Medical Research Center of Oncology, Saint Petersburg, Russia
| | - Anna Artemyeva
- N. N. Petrov National Medical Research Center of Oncology, Saint Petersburg, Russia
| | - Lubov Mitrofanova
- Personalized Medicine Centre, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - Olga Moiseeva
- Non-coronary Heart Disease Department, Almazov National Medical Research Centre, Saint Petersburg, Russia
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13
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Lyu N, Yi JZ, Zhao M. Immunotherapy in older patients with hepatocellular carcinoma. Eur J Cancer 2021; 162:76-98. [PMID: 34954439 DOI: 10.1016/j.ejca.2021.11.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/31/2021] [Accepted: 11/21/2021] [Indexed: 02/06/2023]
Abstract
Hepatocellular carcinoma (HCC) is one of the most common types of cancer globally and is currently the third leading cause of cancer-related deaths. Recently, immunotherapy using immune checkpoint inhibitors (ICIs) has been shown with encouraging anticancer activity and safety in clinical trials. To reverse the phenomenon of tumours evading immune response, ICIs can be used to stimulate the natural antitumour potential of cancer cells by blocking the relevant checkpoints to activate T cells. However, the components and functions of the immune system may undergo a series of changes with ageing, known as 'immunosenescence,' potentially affecting the antitumour effect and safety of immunotherapy. In the current phase III clinical trials of ICIs including nivolumab, pembrolizumab and atezolizumab, the proportion of patients with HCC older than 65 years in CheckMate 459, KEYNOTE-240 and IMbrave150 is 51%, 58% and 50%, respectively, which is less than 70%-73% of epidemiological investigation. Therefore, the elderly population recruited in clinical trials may not accurately represent the real-world elderly patients with HCC, which affects the extrapolation of the efficacy and safety profile obtained in clinical trials to the elderly population in the real world. This review provides the latest advances in ICIs immuno-treatment available for HCC and relevant information about their therapeutic effects and safety on elderly patients. We discuss the benefits of ICIs for older HCC patients, and relevant recommendations about conducting further clinical trials are proposed for more complete answers to this clinical issue.
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Affiliation(s)
- Ning Lyu
- Department of Minimally Invasive Interventional Therapy, Liver Cancer Study and Service Group, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jun-Zhe Yi
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Ming Zhao
- Department of Minimally Invasive Interventional Therapy, Liver Cancer Study and Service Group, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.
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14
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Thakker RA, Lee MA, Albaeni A, Elbadawi A, Suthar KH, Perez C, Sonstein LK, Farr NM, Venkatesan R, Khalife W, Berbarie RF, Chatila KF. Clinical Characteristics and Outcomes in Immune Checkpoint Inhibitor Therapy-Associated Myocarditis. Cardiol Res 2021; 12:270-278. [PMID: 34691324 PMCID: PMC8510657 DOI: 10.14740/cr1319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) therapy has played an important role in the treatment of several groups of cancers. Although a life prolonging treatment, many side effects have been shown with ICI therapy. This study looked at individual level clinical characteristics and outcomes with ICI therapy in patients who developed ICI-related myocarditis. A comprehensive review of the National Library of Medicine PubMed database was performed. Inclusion criteria were all studies that were composed of case reports and case series of individual patients undergoing ICI therapy that developed myocarditis. To appreciate individual patient level data, observational studies, clinical trials, systematic reviews, and meta-analyses were excluded. Our search yielded 333 results with 71 cases reviewed of ICI therapy-related myocarditis. The findings included an average age of 68 years, higher incidence in men, and pretreatment cardiac history of hypertension. Melanoma was the most prevalent malignancy with nivolumab being the most used ICI therapy. Heart failure was the most prevalent adverse event that was co-prevalent with myocarditis. Corticosteroid therapy alone was the most utilized therapy to treat ICI-related myocarditis. Mortality was seen in nearly half of the patient population. Our study reviewed the preexisting literature of prior reported myocarditis secondary to ICI therapy. Periodic surveillance should be performed by the cardio-oncologist and internist. Due to the expanding role of ICI therapy in treating a variety of cancer patients, appreciation of its impact on the development of myocarditis is needed.
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Affiliation(s)
- Ravi A Thakker
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Marissa A Lee
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Aiham Albaeni
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Ayman Elbadawi
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Krishna H Suthar
- Department of Hematology and Medical Oncology, Baylor Scott and White Medical Center, Temple, TX, USA
| | - Christopher Perez
- Cardiovascular Institute, Baylor Scott and White Medical Center, Temple, TX, USA
| | - Lindsay K Sonstein
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Norman M Farr
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Rohit Venkatesan
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Galveston, TX, USA
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Rafic F Berbarie
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Khaled F Chatila
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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15
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Cardiac Toxicity Associated with Immune Checkpoint Inhibitors: A Systematic Review. Cancers (Basel) 2021; 13:cancers13205218. [PMID: 34680365 PMCID: PMC8534225 DOI: 10.3390/cancers13205218] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/02/2021] [Accepted: 10/08/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary This review article addresses the toxic effects on the heart associated with the use of certain cancer-treating drugs known as immune checkpoint inhibitors. These drugs target specific proteins in the cell cycle that are abundantly expressed in cancerous cells; however, they inadvertently damage non-cancerous tissue. In the heart, this occurs in the form of dysfunction or death of smooth muscle cells, leading to consequences such as infection, heart rhythm changes, and hormonally dependent and independent ischemia. This review examines the average and median onset of these drug toxicities as well as antidotes. One key observation is that these side effects are positively skewed, meaning they occur early in cancer treatment. Abstract Immune checkpoint inhibitors are immune stimulatory drugs used to treat many types of cancer. These drugs are antibodies against inhibitory proteins, such as CTLA-4 and PD-1/PD-L1, that are expressed on immune cells. When bound, they allow for increased stimulation of T cells to fight tumor cells. However, immune checkpoint inhibitors have several immune-related adverse effects. Many cases have come to light recently of cardiotoxicity as a result of treatment with these drugs. Cardiotoxicity from immune checkpoint inhibitors is unique due to its rarity and high mortality rate. Patients with this toxicity may present with myocarditis, pericarditis, Takotsubo cardiomyopathy, conduction disorders, and others within just a few weeks of starting immune checkpoint inhibitors. We present here a review of the current research on immune checkpoint inhibitors, their associated cardiotoxicities, the timing of presentation of these conditions, lab tests and histology for each condition, and finally the treatment of patients with cardiotoxicity. We observe a positive skew in the onset of presentation, which is significant for the treating physician.
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Cardiotoxicity associated with immune checkpoint inhibitors and CAR T-cell therapy. Am J Emerg Med 2021; 50:51-58. [PMID: 34274878 DOI: 10.1016/j.ajem.2021.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The expanding use of immunotherapy and the growing population of patients with cancer has led to an increase in the reporting of immune related adverse events (irAEs). The emergency clinician should be aware of these emerging toxicities, some of which can be fatal. In this review we discuss the cardiotoxic side effects of immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T-cell (CAR T-cell) therapy. DISCUSSION Recognizing the possible presentations of cardiotoxic irAEs is of utmost important as the diagnosis of cardiotoxicity associated with ICI and CAR T-cell can be difficult to make in the emergency department. The emergency clinician will have to presume the diagnosis and treat it without final confirmation in most cases. For this reason, if the diagnosis is suspected, early involvement of the cardiologist and oncologist is important to help guide management. Most irAEs will be treated with glucocorticoids, but in the case of CAR T-cell cardiotoxicity, Tocilizumab should be used as first line. CONCLUSION Although cardiotoxicity is rare, it is often life-threatening. Treatment should be initiated as soon as the diagnosis is suspected, and early involvement of the cardiologist and oncologist is imperative for optimal treatment.
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Serzan M, Rapisuwon S, Krishnan J, Chang IC, Barac A. Takotsubo Cardiomyopathy Associated With Checkpoint Inhibitor Therapy: Endomyocardial Biopsy Provides Pathological Insights to Dual Diseases. JACC: CARDIOONCOLOGY 2021; 3:330-334. [PMID: 34396344 PMCID: PMC8352182 DOI: 10.1016/j.jaccao.2021.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/12/2021] [Accepted: 02/14/2021] [Indexed: 12/23/2022]
Affiliation(s)
- Michael Serzan
- Division of Oncology, Department of Medicine, Lombardi Comprehensive Cancer Center, Medstar Georgetown University Hospital, Washington, DC, USA
- Address for correspondence: Dr. Michael Serzan, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA.
| | - Suthee Rapisuwon
- Division of Oncology, Department of Medicine, Lombardi Comprehensive Cancer Center, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Jayashree Krishnan
- Department of Pathology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Ian C. Chang
- Division of Cardiology, Department of Medicine, MedStar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, DC, USA
| | - Ana Barac
- Division of Cardiology, Department of Medicine, MedStar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, DC, USA
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Ziogas IA, Evangeliou AP, Giannis D, Hayat MH, Mylonas KS, Tohme S, Geller DA, Elias N, Goyal L, Tsoulfas G. The Role of Immunotherapy in Hepatocellular Carcinoma: A Systematic Review and Pooled Analysis of 2,402 Patients. Oncologist 2021; 26:e1036-e1049. [PMID: 33314549 DOI: 10.1002/onco.13638] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 12/03/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Immune checkpoints inhibitors (ICIs) have emerged as a treatment option for several malignancies. Nivolumab, pembrolizumab, nivolumab plus ipilimumab, and atezolizumab plus bevacizumab have been approved for the management of advanced-stage hepatocellular carcinoma (HCC). We aimed to systematically review the literature and summarize the characteristics and outcomes of patients with HCC treated with ICIs. METHODS A systematic literature search of PubMed, the Cochrane Library, and ClinicalTrials.gov was performed according to the PRISMA statement (end of search date: November 7, 2020). Quality of evidence assessment was also performed. RESULTS Sixty-three articles including 2,402 patients were analyzed, 2,376 of whom received ICIs for unresectable HCC. Response to ICIs could be evaluated in 2,116 patients; the overall objective response rate (ORR) and disease control rate (DCR) were 22.7% and 60.7%, respectively, and the mean overall survival (OS) was 15.8 months. The ORR, DCR, and OS for nivolumab (n = 846) were 19.7%, 51.1%, and 18.7 months, respectively; for pembrolizumab (n = 435) they were 20.7%, 64.6% and 13.3 months, respectively. The combination of atezolizumab/bevacizumab (n = 460) demonstrated an ORR and DCR of 30% and 77%, respectively. The overall rate of treatment discontinuation because of adverse events was 14.9%. Fifteen patients received ICIs in the liver transplant (LT) setting (one pre-LT for bridging, 14 for post-LT recurrence); fatal graft rejection was reported in 40.0% (n = 6/15) and mortality in 80.0% (n = 12/15). CONCLUSION ICIs are safe and effective against unresectable HCC, but caution is warranted regarding their use in the LT setting because of the high graft rejection rate. IMPLICATIONS FOR PRACTICE This systematic review pooled the outcomes from studies reporting on the use of immune checkpoint inhibitors (ICIs) for the management of 2,402 patients with advanced-stage hepatocellular carcinoma (HCC), 2,376 of whom had unresectable HCC. The objective response rate and disease control rate were 22.7% and 60.7%, respectively, and the mean overall survival was 15.8 months. The overall rate of treatment discontinuation because of adverse events was 14.9%. Fifteen patients received ICIs in the liver transplant (LT) setting (one pre-LT for bridging, 14 for post-LT recurrence). Six of these patients experienced graft rejection (40.0%).
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Affiliation(s)
- Ioannis A Ziogas
- First Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | | | - Dimitrios Giannis
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.,Institute of Health Innovations and Outcomes Research, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Muhammad H Hayat
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Konstantinos S Mylonas
- Department of Cardiothoracic Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Samer Tohme
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David A Geller
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nahel Elias
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lipika Goyal
- Department of Medicine, Division of Medical Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Georgios Tsoulfas
- First Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
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