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Tang M, Dang P, Liu T, Yang K, Wang Y, Tse G, Liu H, Liu Y, Chan JSK, Liu C, Li G. Risk factors and outcomes of pericardial effusion in cancer patients receiving PD-1 inhibitors. Int J Cardiol 2024; 407:132029. [PMID: 38583590 DOI: 10.1016/j.ijcard.2024.132029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Programmed cell death 1 (PD-1) inhibitors can induce various adverse reactions associated with immunity, of which cardiotoxicity is a serious complication. Limited research exists on the link between PD-1 inhibitor use and pericardial effusion (PE) occurrence and outcomes. METHODS We conducted a retrospective study at the First Affiliated Hospital of Xi'an Jiaotong University from 2017 to 2019, comparing cancer patients who developed PE within 2 years after PD-1 inhibitor therapy to those who did not. Our primary outcome was the all-cause mortality rate at one year. We applied the Kaplan-Meier method for survival analysis. Multivariate logistic regression was utilized to identify PE risk factors, adjusting for potential confounders. RESULTS A total of 91 patients were finally included, of whom 39 patients had PE. Compared to non-PE group, one-year all-cause mortality was nearly 5 times higher in PE group (64.10% vs. 13.46%, P < 0.001). Patients who developed PE within 2 years of taking PD-1 inhibitors were significantly associated with increased all-cause mortality compared with those who did not (HR: 6.26, 95%CI: 2.70-14.53, P < 0.001). Multivariable logistic regression showed that use of sintilimab (OR: 14.568, 95%CI: 3.431-61.857, P < 0.001), history of lung cancer (OR: 15.360, 95%CI: 3.276-72.017, P = 0.001), and history of hypocalcemia (OR: 7.076, 95%CI: 1.879-26.649, P = 0.004) were independent risk factors of PE development in patients received PD-1 inhibitors therapy. CONCLUSIONS In cancer patients receiving PD-1 inhibitors, PE was associated with higher one-year mortality. Use of sintilimab, and history of lung cancer or hypocalcemia were linked to PE occurrence.
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Affiliation(s)
- Manyun Tang
- Key Laboratory of Surgical Critical Care and Life Support (Xi'an Jiaotong University), Ministry of Education, China; Department of Hepatobiliary Surgery and Liver Transplantation, The Second Affiliated Hospital of Xi'an Jiaotong University, China
| | - Peizhu Dang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Tong Liu
- Key Laboratory of Surgical Critical Care and Life Support (Xi'an Jiaotong University), Ministry of Education, China; Department of Hepatobiliary Surgery and Liver Transplantation, The Second Affiliated Hospital of Xi'an Jiaotong University, China
| | - Kun Yang
- Key Laboratory of Surgical Critical Care and Life Support (Xi'an Jiaotong University), Ministry of Education, China; Department of Hepatobiliary Surgery and Liver Transplantation, The Second Affiliated Hospital of Xi'an Jiaotong University, China
| | - Yifei Wang
- Key Laboratory of Surgical Critical Care and Life Support (Xi'an Jiaotong University), Ministry of Education, China; Department of Hepatobiliary Surgery and Liver Transplantation, The Second Affiliated Hospital of Xi'an Jiaotong University, China
| | - 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, PowerHealth Limited, Hong Kong, China; School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Hui Liu
- Biobank of The First Affiliated Hospital of Xian Jiaotong University, Xi'an, China
| | - Yufeng Liu
- Biobank of The First Affiliated Hospital of Xian Jiaotong University, Xi'an, China
| | - Jeffrey Shi Kai Chan
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China
| | - Chang Liu
- Key Laboratory of Surgical Critical Care and Life Support (Xi'an Jiaotong University), Ministry of Education, China; Department of Hepatobiliary Surgery and Liver Transplantation, The Second Affiliated Hospital of Xi'an Jiaotong University, China.
| | - Guoliang Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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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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Sharma A, Alexander G, Chu JH, Markopoulos A, Maloul G, Ayub MT, Fidler MJ, Okwuosa TM. Immune Checkpoint Inhibitors and Cardiotoxicity: A Comparative Meta-Analysis of Observational Studies and Randomized Controlled Trials. J Am Heart Assoc 2024; 13:e032620. [PMID: 38761070 PMCID: PMC11179795 DOI: 10.1161/jaha.123.032620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/20/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have uncommon associations with cardiotoxicity, yet these cardiotoxic effects are associated with high mortality. An accurate assessment of risk for cardiotoxicity is essential for clinical decision-making, but data from randomized controlled trials often differ from real-world observational studies. METHODS AND RESULTS A systematic search of PubMed, Embase, Cochrane Library, and Scopus was performed, including phase II and III randomized controlled trials (RCTs) and observational studies (OSs) reporting myocarditis or pericardial disease, myocardial infarction, or stroke with an immunotherapy. Odds ratios (ORs) were used to pool results between ICIs and other cancer therapy in RCTs and OSs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed. In total, 54 RCTs (N=38 264) and 24 OSs (N=12 561 455) were included. In RCTs, ICI use resulted in higher risk of myocarditis (OR, 3.55 [95% CI, 2.10-5.98]), pericardial disease (OR, 2.73 [95% CI, 1.57-4.77]), and myocardial infarction (OR, 1.83 [95% CI, 1.03-3.25]), compared with non-ICI (placebo or chemotherapy). In OSs, ICI use was not associated with myocarditis, pericardial disease, or myocardial infarction compared with controls; however, combination ICIs demonstrated higher risk of myocarditis compared with single ICI use (OR, 3.07 [95% CI, 1.28-7.39]). Stroke risk was not increased with use of ICIs in RCTs. CONCLUSIONS We demonstrated increased risk of ICI myocarditis, pericardial disease, and myocardial infarction in RCTs but not OSs. Results of this study suggest there are differences between ICI cardiotoxicity risk, possibly suggesting differences in diagnoses and management, in clinical trials versus the OSs.
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Affiliation(s)
- Akash Sharma
- Department of Medicine University at Buffalo-Catholic Health System Buffalo NY
- Center for Global Health Research Saveetha Medical College, Saveetha Institute of Medical and Technical Sciences, Saveetha University Chennai India
| | - Grace Alexander
- Department of Internal Medicine University of Iowa Hospitals & Clinics Iowa City IA
| | - Jian H Chu
- Division of Cardiology, Department of Medicine University of Oklahoma Oklahoma City OK
| | | | | | - Muhammad Talha Ayub
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh PA
| | - Mary J Fidler
- Division of Hematology/Oncology/Stem cell transplant Rush University Medical Center Chicago IL
| | - Tochukwu M Okwuosa
- Division of Cardiology, Department of Internal Medicine Rush University Medical Center Chicago IL
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Mudra SE, Rayes DL, Agrawal A, Kumar AK, Li JZ, Njus M, McGowan K, Kalam KA, Charalampous C, Schleicher M, Majid M, Syed A, Yesilyaprak A, Klein AL. Immune checkpoint inhibitors and pericardial disease: a systematic review. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:29. [PMID: 38760863 PMCID: PMC11100143 DOI: 10.1186/s40959-024-00234-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION Despite the growing use of immune checkpoint inhibitors (ICI) in cancer treatment, data regarding ICI-associated pericardial disease are primarily derived from case reports and case series. ICI related pericardial disease can be difficult to diagnose and is associated with significant morbidity. We conducted a systematic review to further characterize the epidemiology, clinical presentation, and outcomes of this patient population. METHODS A search of four databases resulted in 31 studies meeting inclusion criteria. Patients > 18 years old who presented with ICI mediated pericardial disease were included. Intervention was medical + surgical therapy and outcomes were development of cardiac tamponade, morbidity, and mortality. RESULTS Thirty- eight patients across 31 cases were included. Patients were majority male (72%) with a median age of 63. Common symptoms included dyspnea (59%) and chest pain (32%), with 41% presenting with cardiac tamponade. Lung cancer (81%) was the most prevalent, and nivolumab (61%) and pembrolizumab (34%) were the most used ICIs. Pericardiocentesis was performed in 68% of patients, and 92% experienced symptom improvement upon ICI cessation. Overall mortality was 16%. DISCUSSION This study provides the most comprehensive analysis of ICI-mediated pericardial disease to date. Patients affected were most commonly male with lung cancer treated with either Nivolumab or Pembrolizumab. Diagnosis may be challenging in the setting of occult presentation with normal EKG and physical exam as well as delayed onset from therapy initiation. ICI-associated pericardial disease demonstrates high morbidity and mortality, as evidenced by a majority of patients requiring pericardiocentesis.
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Affiliation(s)
- Sarah E Mudra
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Danny L Rayes
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Ankit Agrawal
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Ashwin K Kumar
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Jason Z Li
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Meredith Njus
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Kevin McGowan
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Kazi A Kalam
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Charalompos Charalampous
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Mary Schleicher
- Floyd D. Loop Memorial Library, Cleveland Clinic, Cleveland, OH, USA
| | - Muhammad Majid
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Alvena Syed
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Abdullah Yesilyaprak
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA.
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5
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Palaskas NL, Ali HJ, Koutroumpakis E, Ganatra S, Deswal A. Cardiovascular toxicity of immune therapies for cancer. BMJ 2024; 385:e075859. [PMID: 38749554 DOI: 10.1136/bmj-2023-075859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
In addition to conventional chemoradiation and targeted cancer therapy, the use of immune based therapies, specifically immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T cell therapy (CAR-T), has increased exponentially across a wide spectrum of cancers. This has been paralleled by recognition of off-target immune related adverse events that can affect almost any organ system including the cardiovascular system. The use of ICIs has been associated with myocarditis, a less common but highly fatal adverse effect, pericarditis and pericardial effusions, vasculitis, thromboembolism, and potentially accelerated atherosclerosis. CAR-T resulting in a systemic cytokine release syndrome has been associated with myriad cardiovascular consequences including arrhythmias, myocardial infarction, and heart failure. This review summarizes the current state of knowledge regarding adverse cardiovascular effects associated with ICIs and CAR-T.
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Affiliation(s)
| | - Hyeon-Ju Ali
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sarju Ganatra
- Lahey Hospital and Medical Center, Burlington, MA 01805
| | - Anita Deswal
- University of Texas MD Anderson Cancer Center, Houston, TX, USA 01805
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Jamison K, Medepalli LC, Ye S. Isolated Pericardial Effusion Without Associated Myocarditis in a Small-Cell Lung Cancer Patient Undergoing Atezolizumab Therapy. Cureus 2024; 16:e60184. [PMID: 38868282 PMCID: PMC11167685 DOI: 10.7759/cureus.60184] [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] [Accepted: 05/13/2024] [Indexed: 06/14/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a form of immunotherapy increasingly utilized in cancer therapies. While offering promise in malignancy treatment, ICIs, including atezolizumab, can elicit immune-related adverse events (irAEs) such as cardiotoxicity. We present the case of a 67-year-old male with stage IV metastatic small-cell lung cancer undergoing carboplatin, etoposide, and atezolizumab therapy, who developed pericardial tamponade two months into treatment. Initially presenting with hypoxia on day three of his third treatment cycle, he was admitted due to multifocal pneumonia and subsequently diagnosed with pericardial tamponade stemming from a sizable pericardial effusion. Pericardiocentesis was performed, effectively resolving the tamponade. Infectious etiology was ruled out. Notably, there was no associated myocarditis, as evidenced by negative cardiac markers and magnetic resonance imaging (MRI) findings, and cytologic analysis of the pericardial fluid did not reveal malignant cells, indicating an isolated immunologic etiology for the pericardial effusion. Following successful management, including oxygen support and a prednisone taper, chemotherapy without immunotherapy was resumed after a one-week delay. This rare case underscores the significance of promptly utilizing multimodality imaging with timely cardiology intervention, a prompt pericardial fluid analysis in diagnosing cardiac irAEs, and management leading to improved patient outcomes.
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Affiliation(s)
- Kiara Jamison
- Internal Medicine, Northside Hospital Gwinnett, Lawrenceville, USA
| | - Lalitha C Medepalli
- Cardiology/Cardiooncology, Northside Cardiovascular Institute (NCVI) Northside Hospital, Atlanta, USA
| | - Star Ye
- Oncology, Georgia Cancer Specialists (Affiliated With Northside Hospital Cancer Institute), Canton, USA
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7
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Liu G, Chen T, Zhang X, Hu B, Shi H. Immune checkpoint inhibitor-associated cardiovascular toxicities: A review. Heliyon 2024; 10:e25747. [PMID: 38434280 PMCID: PMC10907684 DOI: 10.1016/j.heliyon.2024.e25747] [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: 07/19/2023] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 03/05/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionary effects on therapeutic strategies for multiple malignancies. Their efficacy depends on their ability to reactivate the host immune system to fight cancer cells. However, adverse reactions to ICIs are common and involve several organs, limiting their use in clinical practice. Although the incidence of cardiovascular toxicity is relatively low, it is associated with serious consequences and high mortality rates. The primary cardiovascular toxicities include myocarditis, pericarditis, Takotsubo syndrome, arrhythmia, vasculitis, acute coronary syndrome, and venous thromboembolism. Currently, the mechanism underlying ICI-associated cardiovascular toxicity remains unclear and underexplored. The diagnosis and monitoring of ICI-associated cardiovascular toxicities mainly include the following indicators: symptoms, signs, laboratory examination, electrocardiography, imaging, and pathology. Treatments are based on the grade of cardiovascular toxicity and mainly include drug withdrawal, corticosteroid therapy, immunosuppressants, and conventional cardiac treatment. This review focuses on the incidence, underlying mechanisms, clinical manifestations, diagnoses, and treatment strategies.
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Affiliation(s)
- Guihong Liu
- Guihong Liu Department of Biotherapy, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Chen
- Tao Chen Department of Cardiology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xin Zhang
- Guihong Liu Department of Biotherapy, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Binbin Hu
- Guihong Liu Department of Biotherapy, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Huashan Shi
- Guihong Liu Department of Biotherapy, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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He Y, Yu H, Dai S, He M, Ma L, Xu Z, Luo F, Wang L. Immune checkpoint inhibitors break whose heart? Perspectives from cardio-immuno-oncology. Genes Dis 2024; 11:807-818. [PMID: 37692505 PMCID: PMC10491874 DOI: 10.1016/j.gendis.2023.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/12/2023] [Indexed: 03/30/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibody antagonists, which can block cytotoxic T lymphocyte antigen-4 (CTLA-4), programmed death-1/ligand-1 (PD-1/PD-L1) pathways, and other molecules exploited by tumor cells to evade T cell-mediated immune response. ICIs have transformed the treatment landscape for various cancers due to their amazing efficacy. Many anti-tumor therapies, including targeted therapy, radiotherapy, and chemotherapy, combine ICIs to make the treatment more effective. However, the off-target immune activation caused by ICIs may lead to a broad spectrum of immune-related adverse events (irAEs) affecting multiple organ systems. Among irAEs, cardiotoxicity induced by ICIs, uncommon but fatal, has greatly offset survival benefits from ICIs, which is heartbreaking for both patients and clinicians. Consequently, such cardiotoxicity requires special vigilance, and it has become a common challenge both for patients and clinicians. This article reviewed the clinical manifestations and influence of cardiotoxicity from the view of patients and clinicians, elaborated on the underlying mechanisms in conjunction with animal studies, and then attempted to propose management strategies from a cardio-immuno-oncology multidisciplinary perspective.
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Affiliation(s)
- Yingying He
- Oncology Department, Deyang People's Hospital, Deyang, Sichuan 618000, China
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Hui Yu
- Cardiovascular Department, Mianyang Central Hospital, Mianyang, Sichuan 621000, China
| | - Shuang Dai
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Miao He
- Oncology Department, Deyang People's Hospital, Deyang, Sichuan 618000, China
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Ling Ma
- Department of Rheumatology and Immunology, Deyang People's Hospital, Deyang, Sichuan 618000, China
| | - Zihan Xu
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Feng Luo
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Li Wang
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
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9
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Mori S, Bertamino M, Guerisoli L, Stratoti S, Canale C, Spallarossa P, Porto I, Ameri P. Pericardial effusion in oncological patients: current knowledge and principles of management. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:8. [PMID: 38365812 PMCID: PMC10870633 DOI: 10.1186/s40959-024-00207-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND This article provides an up-to-date overview of pericardial effusion in oncological practice and a guidance on its management. Furthermore, it addresses the question of when malignancy should be suspected in case of newly diagnosed pericardial effusion. MAIN BODY Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread. Several cancer therapies may also cause pericardial effusion, most often during or shortly after administration. Pericardial effusion following radiation therapy may instead develop after years. Other diseases, such as infections, and, rarely, primary tumors of the pericardium complete the spectrum of the possible etiologies of pericardial effusion in oncological patients. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades. Drainage, which is mainly attained by pericardiocentesis, is needed when cancer or cancer treatment-related pericardial effusion leads to hemodynamic impairment. Placement of a pericardial catheter for 2-5 days is advised after pericardial fluid removal. In contrast, even a large pericardial effusion should be conservatively managed when the patient is stable, although the best frequency and timing of monitoring by echocardiography in this context are yet to be established. Pericardial effusion secondary to immune checkpoint inhibitors typically responds to corticosteroid therapy. Pericardiocentesis may also be considered to confirm the presence of neoplastic cells in the pericardial fluid, but the yield of cytological examination is low. In case of newly found pericardial effusion in individuals without active cancer and/or recent cancer treatment, a history of malignancy, unremitting or recurrent course, large effusion or presentation with cardiac tamponade, incomplete response to empirical therapy with nonsteroidal anti-inflammatory, and hemorrhagic fluid at pericardiocentesis suggest a neoplastic etiology.
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Affiliation(s)
- S Mori
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - M Bertamino
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - L Guerisoli
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - S Stratoti
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - C Canale
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Spallarossa
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - I Porto
- Department of Internal Medicine, University of Genova, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Ameri
- Department of Internal Medicine, University of Genova, Genova, Italy.
- IRCCS Ospedale Policlinico San Martino, Genova, Italy.
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10
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Jo W, Won T, Daoud A, Čiháková D. Immune checkpoint inhibitors associated cardiovascular immune-related adverse events. Front Immunol 2024; 15:1340373. [PMID: 38375475 PMCID: PMC10875074 DOI: 10.3389/fimmu.2024.1340373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are specialized monoclonal antibodies (mAbs) that target immune checkpoints and their ligands, counteracting cancer cell-induced T-cell suppression. Approved ICIs like cytotoxic T-lymphocyte antigen-4 (CTLA-4), programmed death-1 (PD-1), its ligand PD-L1, and lymphocyte activation gene-3 (LAG-3) have improved cancer patient outcomes by enhancing anti-tumor responses. However, some patients are unresponsive, and others experience immune-related adverse events (irAEs), affecting organs like the lung, liver, intestine, skin and now the cardiovascular system. These cardiac irAEs include conditions like myocarditis, atherosclerosis, pericarditis, arrhythmias, and cardiomyopathy. Ongoing clinical trials investigate promising alternative co-inhibitory receptor targets, including T cell immunoglobulin and mucin domain-containing protein 3 (Tim-3) and T cell immunoreceptor with immunoglobulin and ITIM domain (TIGIT). This review delves into the mechanisms of approved ICIs (CTLA-4, PD-1, PD-L1, and LAG-3) and upcoming options like Tim-3 and TIGIT. It explores the use of ICIs in cancer treatment, supported by both preclinical and clinical data. Additionally, it examines the mechanisms behind cardiac toxic irAEs, focusing on ICI-associated myocarditis and atherosclerosis. These insights are vital as ICIs continue to revolutionize cancer therapy, offering hope to patients, while also necessitating careful monitoring and management of potential side effects, including emerging cardiac complications.
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Affiliation(s)
- Wonyoung Jo
- Department of Biomedical Engineering, Johns Hopkins University, Whiting School of Engineering, Baltimore, MD, United States
| | - Taejoon Won
- Department of Pathobiology, University of Illinois Urbana-Champaign, College of Veterinary Medicine, Urbana, IL, United States
| | - Abdel Daoud
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, United States
| | - Daniela Čiháková
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD, United States
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11
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Achim A, Liblik K, Gevaert S. Immune checkpoint inhibitors - the revolutionary cancer immunotherapy comes with a cardiotoxic price. Trends Cardiovasc Med 2024; 34:71-77. [PMID: 36152788 DOI: 10.1016/j.tcm.2022.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/06/2022] [Accepted: 09/19/2022] [Indexed: 12/17/2022]
Abstract
The development of immune checkpoint inhibitors (ICIs) has provided a novel and revolutionary treatment option for previously incurable cancers. However, this major advancement is accompanied by a spectrum of cardiotoxic adverse events that are uncommon but potentially fatal. The oncologic indications of ICIs are becoming increasingly complex, requiring robust clinical monitoring to assess for cardiovascular complications. This is reflected in the recent introduction of the first cardio-oncology guidelines, a sign of the cardiovascular community's recognition that seeks to match this dynamic. The aim of this review is to summarize the cardiac side effects of ICI, with an emphasis on prevalence, diagnosis, and treatment options.
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Affiliation(s)
- Alexandru Achim
- Klinik für Kardiologie, Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Switzerland; "Niculae Stancioiu" Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania.
| | - Kiera Liblik
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
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12
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Green CE, Chacon J, Godinich BM, Hock R, Kiesewetter M, Raynor M, Marwaha K, Maharaj S, Holland N. The Heart of the Matter: Immune Checkpoint Inhibitors and Immune-Related Adverse Events on the Cardiovascular System. Cancers (Basel) 2023; 15:5707. [PMID: 38136253 PMCID: PMC10742007 DOI: 10.3390/cancers15245707] [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: 11/07/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Cancer remains a prominent global cause of mortality, second only to cardiovascular disease. The past decades have witnessed substantial advancements in anti-cancer therapies, resulting in improved outcomes. Among these advancements, immunotherapy has emerged as a promising breakthrough, leveraging the immune system to target and eliminate cancer cells. Despite the remarkable potential of immunotherapy, concerns have arisen regarding associations with adverse cardiovascular events. This review examines the complex interplay between immunotherapy and cardiovascular toxicity and provides an overview of immunotherapy mechanisms, clinical perspectives, and potential biomarkers for adverse events, while delving into the intricate immune responses and evasion mechanisms displayed by cancer cells. The focus extends to the role of immune checkpoint inhibitors in cancer therapy, including CTLA-4, PD-1, and PD-L1 targeting antibodies. This review underscores the multifaceted challenges of managing immunotherapy-related cardiovascular toxicity. Risk factors for immune-related adverse events and major adverse cardiac events are explored, encompassing pharmacological, treatment-related, autoimmune, cardiovascular, tumor-related, social, genetic, and immune-related factors. The review also advocates for enhanced medical education and risk assessment tools to identify high-risk patients for preventive measures. Baseline cardiovascular evaluations, potential prophylactic strategies, and monitoring of emerging toxicity symptoms are discussed, along with the potential of adjunct anti-inflammatory therapies.
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Affiliation(s)
- Chase E. Green
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Jessica Chacon
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Brandon M. Godinich
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Rivers Hock
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Maria Kiesewetter
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Mark Raynor
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Komal Marwaha
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Satish Maharaj
- Department of Internal Medicine, Division of Hematology/Oncology, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 4800 Alberta Ave., El Paso, TX 79905, USA
| | - Nathan Holland
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
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13
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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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14
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Zatarain-Nicolás E, Martín P, Márquez Rodas I, Virizuela J, Martín García A, Mitroi C, Cosín Sales J, Barrios V, Sánchez-Cabo F, Ibañez B, de Castro Carpeño J, López Fernández T. Cardiovascular toxicity of checkpoint inhibitors: review of associated toxicity and design of the Spanish Immunotherapy Registry of Cardiovascular Toxicity. Clin Transl Oncol 2023; 25:3073-3085. [PMID: 37227656 DOI: 10.1007/s12094-023-03217-2] [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: 12/03/2022] [Accepted: 04/29/2023] [Indexed: 05/26/2023]
Abstract
Immune checkpoint inhibitors (ICI) have changed the prognosis of many tumors. However, concerning associated cardiotoxicity has been reported. Little is known about the real-life incidence-specific surveillance protocols or the translational correlation between the underlying mechanisms and the clinical presentation of ICI-induced cardiotoxicity. The lack of data from prospective studies led us to review the current knowledge and to present the creation of the Spanish Immunotherapy Registry of Cardiovascular Toxicity (SIR-CVT), a prospective registry of patients receiving ICI that aims to examine the role of hsa-miR-Chr8:96, (a specific serum biomarker of myocarditis) in the early diagnosis of ICI-induced myocarditis. An exhaustive prospective cardiac imaging study will be performed before and during the first 12 months of treatment. The correlation between clinical, imaging, and immunologic parameters may improve our understanding of ICI-induced cardiotoxicity and enable simpler surveillance protocols. We assess ICI-induced cardiovascular toxicity and describe the rationale of the SIR-CVT.
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Affiliation(s)
- Eduardo Zatarain-Nicolás
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBER-CV (Instituto de Salud Carlos III), Universidad Complutense, Madrid, Spain.
| | - Pilar Martín
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), CIBER-CV (Instituto de Salud Carlos III), Madrid, Spain
| | - Iván Márquez Rodas
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan Virizuela
- Medical Oncology Department, Hospital Universitario Virgen de la Macarena, Seville, Spain
| | - Ana Martín García
- Cardiology Department, Complejo Asistencial Universitario de Salamanca, IBSAL, USAL, CIBER-CV (Instituto de Salud Carlos III), Salamanca, Spain
| | - Cristina Mitroi
- Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBER-CV (Instituto de Salud Carlos III), Madrid, Spain
| | - Juan Cosín Sales
- Agencia de Investigación de la Sociedad Española de Cardiología (AISEC), Madrid, Spain
- Cardiology Department, Hospital Arnau de Vilanova, Universidad CEU-Cardenal Herrera, Valencia, Spain
| | - Vivencio Barrios
- Agencia de Investigación de la Sociedad Española de Cardiología (AISEC), Madrid, Spain
- Cardiology Department, Hospital Universitario Ramon y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Fátima Sánchez-Cabo
- Bioinformatics Unit, Centro Nacional de Investigaciones Cardiovasculares (CNIC), CIBER-CV (Instituto de Salud Carlos III), Madrid, Spain
| | - Borja Ibañez
- Cardiology Department, IIS-Fundación Jiménez Díaz University Hospital, CIBER-CV (Instituto de Salud Carlos III), CNIC, Madrid, Spain
| | | | - Teresa López Fernández
- Cardiology Service, Cardio-Oncology Unit, La Paz University Hospital and IdiPAz Research Institute, Madrid, Spain.
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15
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Valencia EA, Anumolu N, Jha P. Recurrent Pericardial Effusion in a Patient With Delayed Progression of Melanoma Treated With Immune Checkpoint Inhibitors. Cureus 2023; 15:e47727. [PMID: 38021498 PMCID: PMC10676191 DOI: 10.7759/cureus.47727] [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] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Two commonly used immune checkpoint inhibitors (ICIs) utilized in the treatment of metastatic melanoma are nivolumab, a programmed death (PD-1) checkpoint inhibitor, and ipilimumab, a cytotoxic T-lymphocyte antigen (CTLA-4) checkpoint inhibitor. However, due to the activation of the immune system, ICIs have been associated with cardiotoxic immune-related adverse events (irAEs). Here, we present a 40-year-old male with stage 4 metastatic melanoma treated with nivolumab and ipilimumab who developed recurrent pericardial effusions and subsequent constrictive pericarditis 10 months after initiation of treatment. He initially received a total of four cycles and was started on maintenance nivolumab on 8/2022. On 3/23/2023, he complained of chest pain and was found to be hypotensive. He subsequently underwent an emergent pericardiocentesis where 330cc of serosanguinous fluid was drained. Repeat echo on 3/24 demonstrated a re-accumulation of a moderate-sized pericardial effusion, and a subxiphoid pericardial window was placed. He again presented on 5/24/2023 with similar complaints, and a CT scan of chest showed enlarged pericardial effusion with new bilateral pleural effusions. To our knowledge, this is one of few case reports discussing pericardial effusions in the setting of nivolumab and ipilimumab ICI immunotherapy.
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Affiliation(s)
| | | | - Pinky Jha
- Internal Medicine, Medical College of Wisconsin, Wauwatosa, USA
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16
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Kwok C, Nolan M. Cardiotoxicity of anti-cancer drugs: cellular mechanisms and clinical implications. Front Cardiovasc Med 2023; 10:1150569. [PMID: 37745115 PMCID: PMC10516301 DOI: 10.3389/fcvm.2023.1150569] [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: 01/24/2023] [Accepted: 07/17/2023] [Indexed: 09/26/2023] Open
Abstract
Cardio-oncology is an emerging field that seeks to enhance quality of life and longevity of cancer survivors. It is pertinent for clinicians to understand the cellular mechanisms of prescribed therapies, as this contributes to robust understanding of complex treatments and off-target effects, improved communication with patients, and guides long term care with the goal to minimise or prevent cardiovascular complications. Our aim is to review the cellular mechanisms of cardiotoxicity involved in commonly used anti-cancer treatments and identify gaps in literature and strategies to mitigate cardiotoxicity effects and guide future research endeavours.
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Affiliation(s)
- Cecilia Kwok
- Department of Medicine, Western Health, Melbourne, VIC, Australia
| | - Mark Nolan
- Department of Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Cardiovascular Imaging, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
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17
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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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18
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Gong J, Neilan TG, Zlotoff DA. Mediators and mechanisms of immune checkpoint inhibitor-associated myocarditis: Insights from mouse and human. Immunol Rev 2023; 318:70-80. [PMID: 37449556 PMCID: PMC10528547 DOI: 10.1111/imr.13240] [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: 05/20/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
The broad application of immune checkpoint inhibitors (ICIs) has led to significant gains in cancer outcomes. By abrogating inhibitory signals, ICIs promote T cell targeting of cancer cells but can frequently trigger autoimmune manifestations, termed immune-related adverse events (irAEs), affecting essentially any organ system. Among cardiovascular irAEs, immune-related myocarditis (irMyocarditis) is the most described and carries the highest morbidity. The currently recommended treatment for irMyocarditis is potent immunosuppression with corticosteroids and other agents, but this has limited evidence basis. The cellular pathophysiology of irMyocarditis remains poorly understood, though mouse models and human data have both implicated effector CD8+ T cells, some of which are specific for the cardiomyocyte protein α-myosin. While the driving molecular signals and transcriptional programs are not well defined, the involvement of chemokine receptors such as CCR5 and CXCR3 has been proposed. Fundamental questions regarding why only approximately 1% of ICI recipients develop irMyocarditis and why irMyocarditis carries a much worse prognosis than other forms of lymphocytic myocarditis remain unanswered. Further work in both murine systems and with human samples are needed to identify better tools for diagnosis, risk-stratification, and treatment.
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Affiliation(s)
- Jingyi Gong
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Daniel A. Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA
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19
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Khachatryan A, Alejandro JM, Chow RD, Haque RU, Mikdashi JA. Late-Onset Hemorrhagic Pericardial Effusion and Cardiac Tamponade Associated With Immune Checkpoint Inhibitors: Case Report and Literature Review. Cureus 2023; 15:e42867. [PMID: 37664293 PMCID: PMC10473898 DOI: 10.7759/cureus.42867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target T lymphocytes and stimulate the immune system. However, the use of ICIs is associated with immune-related adverse events (irAEs). Pericardial disease is a cardiovascular irAEs that can present as cardiac tamponade. The precise mechanisms underlying pericardial complications are not fully understood. Late-onset hemorrhagic pericardial effusion associated with ICIs is quite rare; the mechanism and predisposing factors are yet to be determined. This case report describes a patient with diffuse large B-cell lymphoma (DLBCL) who received pembrolizumab for 390 days and subsequently developed cardiac tamponade caused by hemorrhagic pericardial effusion. The purpose of this report is to raise awareness about the occurrence of late-onset cardiac tamponade and provide a summary of available data on patients who experienced hemorrhagic pericardial effusion during ICI treatment.
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Affiliation(s)
- Aleksan Khachatryan
- Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, USA
| | - Joel M Alejandro
- Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, USA
| | - Robert D Chow
- Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, USA
| | - Reyaz U Haque
- Cardiology, University of Maryland Medical Center Midtown Campus, Baltimore, USA
| | - Jamal A Mikdashi
- Rheumatology, University of Maryland Medical Center Midtown Campus, Baltimore, USA
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20
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Yousif LI, Screever EM, Versluis D, Aboumsallem JP, Nierkens S, Manintveld OC, de Boer RA, Meijers WC. Risk Factors for Immune Checkpoint Inhibitor-Mediated Cardiovascular Toxicities. Curr Oncol Rep 2023; 25:753-763. [PMID: 37079251 PMCID: PMC10256640 DOI: 10.1007/s11912-023-01414-4] [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] [Accepted: 03/21/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICIs) have improved the field of cancer, especially in patients with advanced malignancies. Nevertheless, cardiovascular immune-related adverse events (irAEs) with high mortality and morbidity have been observed, including myocarditis, pericarditis, and vasculitis. To date, only a few clinical risk factors have been described and are currently being investigated. RECENT FINDINGS In this review, we address the four most prevailing risk factors for cardiovascular irAEs. ICI combination therapy is a predominant risk factor for developing ICI-mediated myocarditis. Additionally, ICI combined with other anti-cancer treatments (e.g., tyrosine kinase inhibitors, radiation, chemotherapy) seems to increase the risk of developing cardiovascular irAEs. Other risk factors include female sex, pre-existing cardiovascular disease, and specific tumors, on which we will further elaborate in this review. An a priori risk strategy to determine who is at risk to develop these cardiovascular irAEs is needed. Insights into the impact of risk factors are therefore warranted to help clinicians improve care and disease management in these patients.
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Affiliation(s)
- Laura I. Yousif
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000CA Rotterdam, The Netherlands
| | - Elles M. Screever
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000CA Rotterdam, The Netherlands
| | - Daniëlle Versluis
- Graduate School of Life Science, Utrecht University, P.O. Box 80125, 3508 TC Utrecht, The Netherlands
| | - Joseph Pierre Aboumsallem
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000CA Rotterdam, The Netherlands
| | - Stefan Nierkens
- Center for Translational Immunology, Utrecht University, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584CS Utrecht, The Netherlands
| | - Olivier C. Manintveld
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000CA Rotterdam, The Netherlands
| | - Rudolf A. de Boer
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000CA Rotterdam, The Netherlands
| | - Wouter C. Meijers
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000CA Rotterdam, The Netherlands
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21
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Chen YC, Jaffer M, Zhou L, Moslehi J, Forsyth PA, Fecher LA. A Brain, A Heart, and the Courage: Balancing Benefit and Toxicity of Immunotherapy in Melanoma. Am Soc Clin Oncol Educ Book 2023; 43:e390594. [PMID: 37229626 DOI: 10.1200/edbk_390594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The overall survival of advanced melanoma has improved dramatically. Immunotherapies, specifically checkpoint inhibitors, have played a large role in this improvement. These agents have also shown benefit in the adjuvant setting, are approved for treatment of resected stage II, III, and IV melanoma, and play an evolving role in the neoadjuvant setting. Although generally well tolerated, immune-related adverse events occur and can be severe. Here we focus on some severe and potentially long term toxicities, including cardiovascular and neurologic toxicities. Our understanding of the acute and long-term toxicities of immune checkpoint inhibitors continues to evolve. Oncologists must continue to balance cancer risk and treatment-related toxicities.
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Affiliation(s)
- Yen-Chou Chen
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
- Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Muhammad Jaffer
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
| | - Lylybell Zhou
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Javid Moslehi
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Peter A Forsyth
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
- Department of Oncology, Moffitt Cancer Center and University of South Florida, Tampa, FL
| | - Leslie A Fecher
- Rogel Cancer Center at the University of Michigan, Ann Arbor, MI
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22
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Verhaert M, Mebis J, Aspeslagh S, von Kemp B. Steroid-dependent pericarditis following anti-PD1 immunotherapy in a metastatic melanoma patient: a case report. Eur Heart J Case Rep 2023; 7:ytad112. [PMID: 36937234 PMCID: PMC10019811 DOI: 10.1093/ehjcr/ytad112] [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: 10/13/2022] [Revised: 11/23/2022] [Accepted: 02/23/2023] [Indexed: 03/06/2023]
Abstract
Background Immune-related adverse events are increasingly prevalent in the oncologist's practice. Cardiac adverse events are rare but can be life-threatening. Case reports of immune checkpoint inhibitor (ICI)-related pericarditis are scarce and so is the scientific evidence for its management. This is the first report of a steroid-dependent pericarditis. Case summary We present a case of a woman with lung metastatic melanoma who developed pericarditis after two infusions of pembrolizumab. The initial response to steroids and colchicine was favourable, and steroids were successfully tapered, after which the immunotherapy was reintroduced. A complete metabolic remission was achieved after six cycles of pembrolizumab, but pericarditis symptoms recur each time the steroid dose is lowered below 10 mg. After introduction of azathioprine, steroids were successfully tapered over the course of 6 months. Discussion Because of the chronicity of the pericarditis, it was hypothesized that an underlying auto-immune pericarditis was triggered by the checkpoint inhibitor and the general guidelines for recurrent idiopathic pericarditis were followed, successfully adding azathioprine to taper steroids to stop.
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Affiliation(s)
| | - Jeroen Mebis
- Medical Oncology, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium
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Yegya-Raman N, Berlin E, Feigenberg SJ, Ky B, Sun L. Cardiovascular Toxicity and Risk Mitigation with Lung Cancer Treatment. Curr Oncol Rep 2023; 25:433-444. [PMID: 36811807 DOI: 10.1007/s11912-023-01387-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Patients with lung cancer often have concomitant cardiovascular comorbidities and receive potentially cardiotoxic therapies. As oncologic outcomes improve, the relative impact of cardiovascular disease on lung cancer survivors is expected to increase. This review summarizes cardiovascular toxicities observed after treatment for lung cancer, as well as recommended risk mitigation strategies. RECENT FINDINGS A variety of cardiovascular events may be observed after surgery, radiation therapy (RT), and systemic therapy. The risk of cardiovascular events after radiation therapy (RT) is higher than previously appreciated (23-32%), and RT dose to the heart is a modifiable risk factor. Targeted agents and immune checkpoint inhibitors have been associated with cardiovascular toxicities distinct from those of cytotoxic agents; these are rare but can be severe and require prompt intervention. Optimization of cardiovascular risk factors is important at all phases of cancer therapy and survivorship. Recommended practices for baseline risk assessment, preventive measures, and appropriate monitoring are discussed herein.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Eva Berlin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Lova Sun
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, West Pavilion, 2nd Floor, Philadelphia, PA, 19104, USA.
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Josan K, Neilan TG. Immune checkpoint inhibitors: acute and chronic cardiovascular complications. Nat Rev Cardiol 2023; 20:73-74. [PMID: 36543993 DOI: 10.1038/s41569-022-00827-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Kiranbir Josan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Zagami P, Nicolò E, Corti C, Valenza C, Curigliano G. New Concepts in Cardio-Oncology. Cancer Treat Res 2023; 188:303-341. [PMID: 38175351 DOI: 10.1007/978-3-031-33602-7_12] [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: 01/05/2024]
Abstract
Cancer and cardiovascular disease are the two major causes of morbidity and mortality in worldwide. Discovering new therapeutic agents for the management of breast cancer (BC) has increased the numbers of cancer survivors but with the risk of cardiovascular adverse events (CV-AEs). All drugs can potentially damage the cardiovascular system, with different types of clinical manifestations from ischemic myocardial disease to vasculitis, thrombosis or pericarditis. An early detection of CV-AEs guarantees an earlier treatment, which is associated with better outcomes. Cardio-oncology field enlarged its studies to improve prevention, monitoring and treatment of all cardiotoxic manifestations related to old or modern oncological agents. A multidisciplinary approach with a close partnership between oncologists and cardiologists is essential for an optimal management and therapeutic decision-making. The aim of this chapter is to review all types of cardiotoxic manifestations related to novel and old agents approved for treatment of BC patients including chemotherapy, anti-HER2 agents, cyclin-dependent kinase 4/6 inhibitors, PolyADP-ribose polymerase (PARP) inhibitors, antiangiogenic drugs and immunotherapy. We also focused our discussion on prevention, monitoring, treatment, and management of CV-AEs.
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Affiliation(s)
- Paola Zagami
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy.
- Department of Oncology and Hematology, University of Milano, Milan, Italy.
| | - Eleonora Nicolò
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milano, Milan, Italy
| | - Chiara Corti
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milano, Milan, Italy
| | - Carmine Valenza
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milano, Milan, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milano, Milan, Italy
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Drug-induced pericarditis. COR ET VASA 2022. [DOI: 10.33678/cor.2022.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Chiang CH, Chiang CH, Ma KSK, Hsia YP, Lee YW, Wu HR, Chiang CH, Peng CY, Wei JCC, Shiah HS, Peng CM, Neilan TG. The incidence and risk of cardiovascular events associated with immune checkpoint inhibitors in Asian populations. Jpn J Clin Oncol 2022; 52:1389-1398. [PMID: 36208180 PMCID: PMC9721460 DOI: 10.1093/jjco/hyac150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/30/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Immune checkpoint inhibitors are associated with adverse cardiovascular events. However, there are no data characterizing cardiovascular events among Asians on immune checkpoint inhibitors. We aim to determine the incidence and risk of cardiac events associated with immune checkpoint inhibitors in an Asian population. METHODS We performed a retrospective, propensity score-matched cohort study at two tertiary referral centers in Taiwan. Immune checkpoint inhibitor users were matched with non-immune checkpoint inhibitor users based on predetermined clinical variables. The primary outcome was major adverse cardiovascular events, defined as a composite of myocardial infarction, ischemic stroke, acute peripheral occlusive disease, pulmonary embolism, deep venous thrombosis, heart failure, pericardial disease, myocarditis, cardiac arrhythmias and conduction block. RESULTS Between January 2010 and November 2021, 868 immune checkpoint inhibitor users were matched 1:1 with non-immune checkpoint inhibitor users. Among immune checkpoint inhibitor users, 67 (7.7%) patients developed major adverse cardiovascular events. During a median follow-up period of 188 days, the incidence rate of major adverse cardiovascular events for immune checkpoint inhibitor and non-immune checkpoint inhibitor users was 94.8 and 46.2 per 1000 patient-years, respectively, resulting in an incidence rate ratio of 2.1 [95% confidence interval: 1.5-2.9]. In multivariate Cox proportional hazard models, immune checkpoint inhibitor users had a 60% increased risk for major adverse cardiovascular events [hazard ratio, 1.6 (95% confidence interval: 1.1-2.3)]. Immune checkpoint inhibitors use was independently associated with increased risk of ischemic stroke [hazard ratio, 3.0 (95% confidence interval: 1.0-9.0)] and pulmonary embolism [hazard ratio, 5.5 (95% confidence interval: 1.4-21.3)]. In multivariate logistic regression analysis, age > 65, metastatic disease, hypertension and baseline platelet-to-lymphocyte ratio < 180 were risk factors for major adverse cardiovascular events. CONCLUSIONS Among Asians, immune checkpoint inhibitors were associated with an increased risk of major adverse cardiovascular events, particularly ischemic stroke and pulmonary embolism.
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Affiliation(s)
- Cho-Han Chiang
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, MA, USA
| | - Cho-Hung Chiang
- Department of General Division, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kevin Sheng-Kai Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Graduate Institute of Biomedical Electronics and Bioinformatics, College of Electrical Engineering and Computer Science, National Taiwan University, Taipei, Taiwan
| | - Yuan Ping Hsia
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Foundation, New Taipei City, Taiwan
| | - Yu-wen Lee
- Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Han-Ru Wu
- Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Cho-Hsien Chiang
- Department of Medical Education, Kuang Tien General Hospital, Taichung, Taiwan
- London School of Hygiene & Tropical Medicine, London, UK
| | - Chun-Yu Peng
- Department of Medicine, Danbury Hospital, Danbury, Connecticut, USA
- Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Her-Shyong Shiah
- Department of Hematology and Oncology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Ming Peng
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Foundation, New Taipei City, Taiwan
- Da Vinci Minimally Invasive Surgery Center, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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Thuny F, Naidoo J, Neilan TG. Cardiovascular complications of immune checkpoint inhibitors for cancer. Eur Heart J 2022; 43:4458-4468. [PMID: 36040835 PMCID: PMC10263267 DOI: 10.1093/eurheartj/ehac456] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/07/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022] Open
Abstract
Over the last decade or so, there has been a paradigm shift in the oncologic care of patients with a range of solid tumour and haematologic malignancies, away from traditional cytotoxic chemotherapy and towards personalized cancer treatments, using both targeted therapy and immunotherapy. This shift has contributed to the remarkable and sustained increase in the number of cancer survivors and the longevity of patients with a cancer diagnosis. This review will focus on the cardiovascular effects of immune checkpoint inhibitors and will present a background on immune checkpoint inhibition for cancer, the epidemiology, potential mechanisms, the potential insights into cardiovascular biology, and a diagnostic and therapeutic approach to potential cases. Our understanding of the cardiovascular effects of immune checkpoint inhibitors needs to improve. However, the evolution necessarily needs to be rapid. Initial observations noted that immune checkpoint inhibitor therapy can lead to a fulminant myocarditis. Recent reports have expanded the effect of immune checkpoint inhibitor therapy on the cardiovascular system to include an increase in cardiac dysfunction without myocarditis, arrhythmias, venous thromboembolic disease, accelerated atherosclerosis, and atherosclerosis-related cardiovascular events. The association between immune checkpoint inhibitor therapy and an increase in these cardiovascular events is not only limited to events occurring within the first few weeks after starting therapy but can also include events that occur months to years after therapy. The latter observation is especially of relevance in those treated with adjuvant or neoadjuvant therapy. There needs to be a shift from recognition of an increase in cardiovascular events to currently approved immune checkpoint inhibitor therapies to understanding the mechanisms that lead to adverse cardiovascular effects, understanding who is at risk, and understanding what we can do about it.
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Affiliation(s)
- Franck Thuny
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Centre for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Marseille, France
| | - Jarushka Naidoo
- Sidney Kimmel Comprehensive Cancer Center, John Hopkins University, Baltimore, MD, USA
- Beaumont Hospital and RCSI University of Health Sciences, Dublin, Ireland
| | - Tomas G Neilan
- Division of Cardiology and Department of Radiology, Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, Boston, MA, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 675] [Impact Index Per Article: 337.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Immune-Related Uncommon Adverse Events in Patients with Cancer Treated with Immunotherapy. Diagnostics (Basel) 2022; 12:diagnostics12092091. [PMID: 36140493 PMCID: PMC9498261 DOI: 10.3390/diagnostics12092091] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/06/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Immunotherapy has dramatically changed the therapeutic landscape of oncology, and has become standard of care in multiple cancer types in front or late lines of therapy, with some longstanding responses and outstanding results. Notwithstanding, its use has brought a totally unique spectrum of adverse events, characterized by a myriad of diverse manifestations affecting nearly every organ and system of the body, including the endocrine, nervous, cardiac, respiratory and gastrointestinal systems. Uncommon adverse events, defined as those occurring in less than 1% of patients, comprise an even more heterogeneous group of diseases that are being seen more recurrently as the use of immune check-point inhibitors increases and indications spread in different tumor types and stages. Here, we comprehensively review some uncommon, but exceedingly important, immune-related adverse events, with special emphasis in the clinical approach and diagnostic workup, aiming to reunite the evidence published previously, allowing an increase in awareness and knowledge from all specialists implicated in the diagnosis, treatment, and care of cancer patients treated with immunotherapy.
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31
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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32
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Chye AM, Nordman IIC, Sverdlov AL. Successful immune checkpoint inhibitor rechallenge after immune-related pericarditis: Clinical case series. Front Cardiovasc Med 2022; 9:964324. [PMID: 36017099 PMCID: PMC9395697 DOI: 10.3389/fcvm.2022.964324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/22/2022] [Indexed: 12/26/2022] Open
Abstract
Pericardial diseases secondary to immune checkpoint inhibitors (ICI) are rare. Here, we describe two cases of immune-related pericarditis caused by ICI for treatment of advanced NSCLC. Select patients can be successfully rechallenged with ICI after immune-related pericardial disease.
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Affiliation(s)
- Adrian M. Chye
- Calvary Mater Newcastle, Newcastle, NSW, Australia
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Ina I. C. Nordman
- Calvary Mater Newcastle, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Aaron L. Sverdlov
- Calvary Mater Newcastle, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Cardiovascular Department, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, NSW, Australia
- Newcastle Centre of Excellence in Cardio-Oncology, New Lambton Heights, NSW, Australia
- *Correspondence: Aaron L. Sverdlov
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Pohl J, Totzeck M, Mincu RI, Margraf SM, Scheipers L, Michel L, Mahabadi AA, Zimmer L, Rassaf T, Hendgen-Cotta UB. Right ventricular and atrial strain in patients with advanced melanoma undergoing immune checkpoint inhibitor therapy. ESC Heart Fail 2022; 9:3533-3542. [PMID: 35894541 DOI: 10.1002/ehf2.14094] [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: 04/13/2022] [Revised: 06/03/2022] [Accepted: 07/10/2022] [Indexed: 11/08/2022] Open
Abstract
AIMS While immune checkpoint inhibitor (ICI) therapy significantly improves survival rates in advanced melanoma, ICI can evoke severe immune-related cardiovascular adverse events. Right ventricular (RV) dysfunction negatively impacts the outcomes in cardiovascular diseases and may be an early sign for overall cardiotoxicity. We aimed to assess RV function in melanoma patients undergoing ICI therapy using conventional echocardiographic and strain imaging techniques. METHODS AND RESULTS We retrospectively examined 30 patients (40% women, age 59 ± 13 years) with advanced melanoma (stage III/IV) before and 4 weeks after the start of ICI therapy (follow-up at 39 ± 15 days); n = 15 of the patients received nivolumab, and n = 15 received the combination therapy nivolumab/ipilimumab. Two-dimensional echocardiography with assessment of RV longitudinal strain of the free wall (RV-LSFW) and assessment of right atrial (RA) strain from speckle tracking was performed at baseline and after the start of ICI therapy. Short-term ICI therapy caused a reduction of RV-LSFW (-25.5 ± 6.4% vs. -22.4 ± 4.3%, P = 0.002) and of RA strain during contraction phase (-10.6 ± 3.5% vs. -7.7 ± 3.1%, P = 0.001). Conventional parameters including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and pulmonary artery systolic pressure were not different between the two time points (TAPSE 26 ± 5 vs. 25 ± 5 mm, P = 0.125; FAC 38 ± 13% vs. 38 ± 14%, P = 0.750; and pulmonary artery systolic pressure 27 ± 10 vs. 25 ± 8 mmHg, P = 0.268). CONCLUSIONS Analysis of RV and RA strain shows alterations even in a short-term follow-up, while changes in RV function are not visible by conventional RV parameters. Alterations in RV and RA strain could be early signs of cardiotoxicity and therefore should be assessed in patients undergoing ICI therapy.
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Affiliation(s)
- Julia Pohl
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Raluca-I Mincu
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Simone M Margraf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Lena Scheipers
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Amir A Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Ulrike B Hendgen-Cotta
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
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Xiao J, Liu T, Liu Z, Xiao C, Du J, Zuo S, Li H, Gu H. A Differentiation-Related Gene Prognostic Index Contributes to Prognosis and Immunotherapy Evaluation in Patients with Hepatocellular Carcinoma. Cells 2022; 11:cells11152302. [PMID: 35892599 PMCID: PMC9367442 DOI: 10.3390/cells11152302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/14/2022] [Accepted: 07/21/2022] [Indexed: 12/04/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common gastrointestinal tumor with a poor prognosis, which is associated with poor differentiation of tumor cells. However, the potential value of cell differentiation-related molecules in predicting the benefit and prognosis of immune checkpoint inhibitors (ICI) therapy remains unknown. Herein, to investigate the differentiation trajectory of HCC cells and their clinical significance, a differentiation-related gene prognostic index (DRGPI) based on HCC differentiation-related genes (HDRGs) was constructed to elucidate the immune characteristics and therapeutic benefits of ICI in the HCC subgroup defined by DRGPI. Single-cell RNA sequencing (scRNA-seq) and bulk RNA-seq data from four HCC samples were integrated for bioinformatics analysis. Then, PON1, ADH4, SQSTM1, HSP90AA1, and STMN1 were screened out to construct a DRGPI. More intriguingly, RT-qPCR validation of the expression of these genes yielded consistent results with the TCGA database. Next, the risk scoring (RS) constructed based on DRGPI suggested that the overall survival (OS) of the DRGPI-high patients was significantly worse than that of the DRGPI-low patients. A nomogram was constructed based on DRGPI-RS and clinical characteristics, which showed strong predictive performance and high accuracy. The comprehensive results indicated that a low DRGPI score was associated with low TP53 mutation rates, high CD8 T cell infiltration, and more benefit from ICI therapy. Homoplastically, the high DRGPI score reflected the opposite results. Taken together, our study highlights the significance of HCC cell differentiation in predicting prognosis, indicating immune characteristics, and understanding the therapeutic benefits of ICI, and suggests that DRGPI is a valuable prognostic biomarker for HCC.
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Affiliation(s)
- Jingjing Xiao
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550000, China; (J.X.); (T.L.); (C.X.); (J.D.); (S.Z.); (H.L.)
- Department of Hepatobiliary Surgery, Guizhou Provincial People’s Hospital, Guiyang 550002, China;
- Department of Pediatric Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, China
| | - Tao Liu
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550000, China; (J.X.); (T.L.); (C.X.); (J.D.); (S.Z.); (H.L.)
- Department of Hepatobiliary Surgery, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Zhenhua Liu
- Department of Hepatobiliary Surgery, Guizhou Provincial People’s Hospital, Guiyang 550002, China;
| | - Chuan Xiao
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550000, China; (J.X.); (T.L.); (C.X.); (J.D.); (S.Z.); (H.L.)
| | - Jun Du
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550000, China; (J.X.); (T.L.); (C.X.); (J.D.); (S.Z.); (H.L.)
- Department of Pediatric Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, China
| | - Shi Zuo
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550000, China; (J.X.); (T.L.); (C.X.); (J.D.); (S.Z.); (H.L.)
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, China
| | - Haiyang Li
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550000, China; (J.X.); (T.L.); (C.X.); (J.D.); (S.Z.); (H.L.)
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, China
| | - Huajian Gu
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550000, China; (J.X.); (T.L.); (C.X.); (J.D.); (S.Z.); (H.L.)
- Department of Pediatric Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, China
- Correspondence: ; Tel.: +86-851-8677-2723
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Wang CY, Zoungas S, Voskoboynik M, Mar V. Cardiovascular disease and malignant melanoma. Melanoma Res 2022; 32:135-141. [PMID: 35377865 DOI: 10.1097/cmr.0000000000000817] [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: 11/25/2022]
Abstract
In the last decade, systemic therapies such as immune checkpoint inhibitors and BRAF-MEK inhibitors have improved the prognosis of high-risk and advanced melanoma. With improved survival, melanoma survivorship is increasingly important, particularly in patients who have a good prognosis or are diagnosed at a younger age. It is increasingly recognized that cancer and its treatment is associated with increased cardiovascular morbidity and mortality. Indeed, data from observational studies and meta-analyses of randomized controls trials in melanoma show that systemic therapies may be associated with cardiac toxicities, such as myocardial infarction, heart failure, myocarditis and stroke. Our review will discuss cardiovascular disease and risk factors in the context of melanoma and outline the importance of cardiovascular risk modification in this population.
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Affiliation(s)
- Charlie Yue Wang
- Victorian Melanoma Service, The Alfred Hospital
- School of Public Health and Preventative Medicine, Monash University
| | - Sophia Zoungas
- School of Public Health and Preventative Medicine, Monash University
| | - Mark Voskoboynik
- Department of Oncology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Victoria Mar
- Victorian Melanoma Service, The Alfred Hospital
- School of Public Health and Preventative Medicine, Monash University
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The Diagnosis and Management of Immune Checkpoint Inhibitor Cardiovascular Toxicity: Myocarditis and Beyond. Vaccines (Basel) 2022; 10:vaccines10020304. [PMID: 35214762 PMCID: PMC8879796 DOI: 10.3390/vaccines10020304] [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: 01/11/2022] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 01/25/2023] Open
Abstract
Recent years have brought major advancements in the use of immune therapy and specifically immune checkpoint inhibitors (ICIs) in cancer patients, with expanding indications for various malignancies resulting in the treatment of a large and increasing number of patients. While this therapy significantly improves outcomes in a variety of hematologic and solid tumors, the use of ICIs is associated with a substantial risk of immune-related adverse events. Cardiovascular toxicity, while not the most common side effect of ICIs, is associated with significant morbidity and mortality. It is therefore crucial for oncologists and cardiologists, as well as internists and emergency room physicians, to have a good understanding of this increasingly common clinical problem. In the present review, we discuss the cardiac aspects of ICI therapy with special emphasis on the clinical manifestations of their cardiovascular toxicity, diagnostic approaches, treatment and suggested surveillance.
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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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