Acute Anterior Myocardial Infarction After Chemotherapy for Testicular Seminoma in a Young Patient

Revisiting treatment-related cardiotoxicity in patients with malignant lymphoma-a review and prospects for the future

Treatment of malignant lymphoma has for years been represented by many cardiotoxic agents especially anthracyclines, cyclophosphamide, and thoracic irradiation. Although they are in clinical practice for decades, the precise mechanism of cardiotoxicity and effective prevention is still part of the research. At this article we discuss most routinely used anti-cancer drugs in chemotherapeutic regiments for malignant lymphoma with the focus on novel insight on molecular mechanisms of cardiotoxicity. Understanding toxicity at molecular levels may unveil possible targets of cardioprotective supportive therapy or optimization of current therapeutic protocols. Additionally, we review novel specific targeted therapy and its challenges in cardio-oncology.

Case of ST-Elevation Myocardial Infarction in a 32-Year-Old Male Receiving Bleomycin, Etoposide, and Cisplatin Chemotherapy for Embryonal Carcinoma

Myocardial infarction in young individuals has unique risk factors compared to the older population. Along with usual risk factors, one should explore causes such as recreational drug use, medication-induced myocardial infarction, and spontaneous coronary artery dissection. Here, we present the case of a 32-year-old male who presented with chest pain and was found to have complete thrombotic occlusion of the right coronary artery. He recently started receiving chemotherapy with bleomycin, etoposide, and cisplatin (PEB). In the absence of other risk factors and previous reports of similar cardiotoxicity with bleomycin, the patient was deemed to have an adverse effect from the chemotherapy regimen.

Management of ischemic coronary disease in patients receiving chemotherapy: an uncharted clinical challenge

Acute coronary syndrome (ACS) coinciding with active malignancy presents a unique clinical challenge given intersecting pathophysiology and treatment-related effects. There is little established clinical guidance on management strategies, rendering most treatment approaches anecdotal. We present a case highlighting the complexity of managing a patient being treated for malignancy who concurrently suffers from ACS. We then review the literature on co-management of ACS and malignancy, including reports of specific cancer therapies associated with ACS, unique features of clinical presentation and optimal use of dual antiplatelet therapy to minimize risks of bleeding and thrombosis. We also describe gaps in current literature, challenges in systematically studying the clinical intersection of these disease processes and propose alternative methodologies for further research.

Pathophysiology of cardiotoxicity induced by nonanthracycline chemotherapy

The risk and mechanism of chemotherapy-induced cardiotoxicity (CTX) vary depending on the type and intensity of the anticancer regimen. Myriad chemotherapeutic drugs produce adverse cardiovascular effects such as arterial hypertension, heart failure, and thromboembolic events. Among the numerous classes of these drugs, anthracyclines have been studied most extensively because of their overt cardiovascular effects and the high associated incidence of heart failure. However, CTX might also be caused by other types of chemotherapeutic agents, including alkylating agents (cyclophosphamide, ifosfamide), platinum agents, antimetabolites (5-fluorouracil, capecitabine), antibiotics (mitoxantrone, mitomycin, bleomycin), and antimicrotubule agents (taxanes). Here, we review the incidence, clinical impact, and potential mechanisms of CTX associated with nonanthracycline chemotherapy used for cancer patients. The published data support a marked increase in CTX risk, particularly with certain drugs such as 5-fluorouracil and cisplatin. Each anticancer regimen is associated with distinct modes of heart damage, both symptomatic and asymptomatic. However, the underlying mechanisms of CTX have been established only in a few cases, and only few nonanthracycline chemotherapeutics (mitoxantrone, mitomycin, ifosfamide) act through a recognizable mechanism and show a predictable dose dependence. Lastly, nonanthracycline chemotherapy can induce both chronic lesions, such as systolic dysfunction, and acute lesions, such as the ischemia that occurs within hours or days after treatment. An increased understanding of the incidence, mechanisms, and potential therapeutic targets of CTX induced by various nonanthracycline chemotherapeutic agents is clearly required.

Silencing of PKC-α, TRPC1 or NF-κB expression attenuates cisplatin-induced ICAM-1 expression and endothelial dysfunction

Platinum-based chemotherapy has been associated with increased long-term cardiovascular events. Also noteworthy is the accumulating awareness of early vascular toxicity occurring at the time of chemotherapy or immediately thereafter. The objective of the study was to delineate the molecular mechanisms associated with the early vascular toxicity and test the molecular silencing approach towards attenuating the endothelial dysfunction during platinum-based chemotherapy. Human umbilical vein endothelial cells (HUVECs) were treated with varying concentrations of cisplatin (1.0-10.0μg/ml) or vehicle control (0.1% dimethyl sulfoxide) for monitoring the changes in Intercellular adhesion molecule-1 (ICAM-1) mRNA and protein expression viz. a viz. altered activation of protein kinase C (PKC) isoforms, transient receptor potential channel (TRPC) 1 expression, Nuclear factor 'kappa-light-chain-enhancer' of activated B-cells (NF-κB), Store Operated Ca(2+) Entry (SOCE) in cisplatin-induced endothelial permeability and adherence of the activated endothelial cells to human monocyte-like U937 cells. Silencing of either PKC-α, TRPC1 or p65 subunit of NF-κB, all resulted in significant alleviation of cisplatin-induced endothelial dysfunction. At concentrations ≥8μg/ml, cisplatin induced a significant increase in the expression of ICAM-1 mRNA as well as protein. This was mediated by changes in PKC-α membrane translocation, NF-κB activation, increased expression as well as phosphorylation of TRPC1 and enhanced SOCE, leading to hyperpermeability and leakage of albumin. Increased adherence of U937 monocytes to cisplatin-activated endothelial cells was evident. Cisplatin challenge activates PKC-α, which in turn phosphorylated TRPC1 resulting in enhanced Ca(2+) entry. Increased Ca(2+) flux is required for activation of NF-κB and ICAM-1 expression. Enhanced ICAM-1 expression promotes monocyte binding to endothelial cells and increased endothelial hyperpermeability.

Acute aortic thrombosis in patients receiving cisplatin-based chemotherapy

The increased risk of thrombosis in patients with active cancer has multiple causes. Acute thrombosis of the aorta is an exceedingly rare but potentially devastating complication in patients with cancer receiving cisplatin-based chemotherapy. Prompt diagnosis and definitive treatment are imperative to decrease morbidity and mortality. Early diagnosis is difficult because initial presentation is often nonspecific, requiring a high degree of clinical suspicion. We report 4 cases of acute thrombosis of the abdominal aorta in patients with cancer receiving cisplatin-based chemotherapy. We review the clinical aspects, recommended investigation, and treatment of this potentially fatal complication.

Novel platinum-N-heterocyclic carbene complex is more cardiotoxic than cis-platin in rats

Cis-platin and other platinum complexes are important chemotherapeutic agents useful in the treatment of several cancers. However, therapeutic usage of cis-platin and other platinum complex are limited by their undesirable side effects including cardiotoxicity. In this context, we aimed to compare the damage caused in heart by cis-platin and novel platinum-N-heterocyclic carbene (Pt-NHC) complex. For this purpose, 35 Sprague-Dawley rats were divided randomly into five equal groups (n = 7 for each group). Cis-platin and novel Pt-NHC complex were intraperitoneally administered at a single dose of 5 mg/kg and 10 mg/kg and then sacrificed 10 days after this treatment. The heart tissues were taken from all rats for determination of oxidative and myocardial damage. Cis-platin and novel Pt-NHC complex caused oxidative and histological damage in the heart tissue in a dose-dependent manner (p < 0.05). On the other hand, at the same dose levels, cis-platin caused lower oxidative and histological damage in heart tissue compared to novel Pt-NHC complex. These results suggest that novel Pt-NHC complex is more cardiotoxic than cis-platin.

Etoposide-related cardiotoxicity in a child with haemophagocytic lymphohistiocytosis

We report a male child with haemophagocytic lymphohistiocytosis who developed myocardial infarction after receiving etoposide. He recovered well with supportive measures and after discontinuation of etoposide. We discuss the possible mechanisms and differential diagnoses of myocardial infarction in our patient.

Myocardial infarction and other major vascular events during chemotherapy for testicular cancer

BACKGROUND

Chronic vascular morbidity resulting from chemotherapy for testicular germ-cell cancer (TGCC) is recognized. Cardiovascular events (CVEs) occurring early during chemotherapy are less understood. We evaluated the incidence and clinical features of CVEs associated with chemotherapy of TGCC.

PATIENTS AND METHODS

A questionnaire was sent to 355 institutions in Germany to explore for early CVEs occurring during 1996-2008. To assess the relative incidence of CVEs, the number of events was put into relation to the total number of patients treated during the time span (n = 8233, calculated from national database). The response rate was 79%.

RESULTS

Twenty cases with myocardial infarction (MI), 3 with cerebral stroke, and 2 with arterial thrombosis were recorded. The estimated incidence of MI and of all CVEs during chemotherapy is 0.24% [95% confidence intervals (CIs) 0.137% to 0.349%] and 0.30% (95% CI 0.188% to 0.423%), respectively. This estimate represents a minimum figure because the calculation is on the basis of simplifications. Six MI patients had no risk factors. Coronary angiography was indicative of thromboembolic rather than atherosclerotic origin of MI.

CONCLUSIONS

There is a small but definite risk of major early CVE associated with chemotherapy of TGCC. Physicians caring for TGCC patients must be aware of this hazard.

Thrombosis of abdominal aorta during cisplatin-based chemotherapy of testicular seminoma - a case report

Background

Vascular complications occurring during cisplatin-based chemotherapy of germ cell tumours are inadequately recognized to date.

Case Presentation

A 49 year old man with advanced seminoma underwent two courses of chemotherapy according to the PEB regimen. Upon restaging, two thrombotic deposits were noted in the descending part of the thoracic aorta and in the infrarenal abdominal aorta, respectively. Although thrombotic plaques caused aortic occlusion of about 30%, no clinical signs of malperfusion of limbs were registered. The patient was placed on anticoagulant therapy. Six months after completion of chemotherapy, thrombotic deposits had completely resolved. In the absence of other predisposing factors, it must be assumed that cisplatin-based chemotherapy represented a strong stimulus for arterial thrombosis in the aorta.

Conclusions

This is the first case of endo-aortic thrombosis during chemotherapy for testicular germ cell cancer. Providers of chemotherapy must be aware of arterial thrombosis even in young patients with testicular cancer.

Cisplatin compromises myocardial contractile function and mitochondrial ultrastructure: role of endoplasmic reticulum stress

1. Cisplatin is a potent chemotherapeutic agent with broad-spectrum antineoplastic activity against various types of tumours. However, a major factor limiting treatment with cisplatin is its acute and cumulative cardiotoxicity. The aim of the present study was to explore the effect of cisplatin on myocardial contractile function and the possible underlying cellular mechanisms. 2. C57 mice were treated with cisplatin (10 mg/kg per day, i.v.) or vehicle (0.9% NaCl) for 1 week and myocardial function was assessed using the Langendorff and cardiomyocyte edge-detection systems. Transmission electron microscopy, mitochondrial membrane potential, indices of endoplasmic reticulum (ER) stress and caspase 3 activity were evaluated. 3. Cisplatin-treated mice developed myocardial contractile dysfunction, as evidenced by a reduction in left ventricular developed pressure (LVDP) and the first derivative of LVDP (+/-dP/dt). Cisplatin treatment significantly prolonged time to 90% relengthening, depressed peak shortening, maximal velocity of shortening/relengthening (+/-dL/dt) and augmented the frequency-elicited depression in peak shortening. The JC-1 fluorescent assay demonstrated that cispatin-induced cardiac dysfunction was associated with mitochondrial membrane depolarization. Transmission electron microscopy revealed that cisplatin induces ultrastructural abnormalities of the mitochondria. Following cisplatin treatment, cardiomyocytes show activation of the ER stress response, increased caspase 3 activity and increased terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick end-labelling (TUNEL) staining. 4. The data indicate that cisplatin is cardiotoxic and may lead to left ventricular dysfunction and depressed cardiomyocyte contraction associated with mitochondrial abnormalities, enhanced ER stress and apoptosis. This work should shed some light on the management of cisplatin-induced cardiac injury.

Cardiotoxicity of antitumor drugs

Many antitumor drugs cause "on treatment" cardiotoxicity or introduce a measurable risk of delayed cardiovascular events. Doxorubicin and other anthracyclines cause congestive heart failure that develops in a dose-dependent manner and reflects the formation of toxic drug metabolites in the heart. Cardiovascular events may occur also with other chemotherapeutics, but the dose or metabolism dependence of such events are less obvious and predictable. Drugs targeted to tumor-specific receptors or metabolic routes were hoped to offer a therapeutic gain while also sparing the heart and other healthy tissues; nonetheless, many such drugs still cause moderate to severe cardiotoxicity. Targeted drugs may also engage a cardiotoxic synergism with "old-fashioned" chemotherapeutics, as shown by the higher than expected incidence of anthracycline-related congestive heart failure that occurred in patients treated with doxorubicin and the anti HER2 antibody Trastuzumab. Mechanism-based considerations and retrospective analyses of clinical trials now form the basis for a new classification of cardiotoxicity, type I for anthracyclines vs type II for Trastuzumab. Such a classification may serve a template to accommodate other paradigms of cardiotoxicity induced by new drugs and combination therapies. Of note, laboratory animal models did not always anticipate the mechanisms and/or metabolic determinants of cardiotoxicity induced by antitumor drugs or combination therapies. Toxicologists and regulatory agencies and clinicians should therefore join in collaborative efforts that improve the early identification of cardiotoxicity and minimize the risks of cardiac events in patients.