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Veltmaat L, Cortes J. Arterio-occlusive events among patients with chronic myeloid leukemia on tyrosine kinase inhibitors. Blood 2024; 143:858-865. [PMID: 38194683 DOI: 10.1182/blood.2023022403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/11/2024] Open
Abstract
ABSTRACT Tyrosine kinase inhibitors (TKIs) are standard therapy for patients with chronic myeloid leukemia. Each of these drugs has a specific profile of tyrosine kinases that they inhibit and, although all are clinically effective, they each have unique toxicity profiles. With the introduction of ponatinib, arterio-occlusive events were first noted and later found to occur with all TKIs to various extents. The recognition of this "class effect" was delayed considering ponatinib was introduced 10 years after the introduction of imatinib. The reasons for the delay in identification of this class effect are likely multifaceted. Importantly, there is an inconsistency in adverse event reporting criteria among the major clinical trials of the various TKIs, likely resulting in mixed reporting of arterio-occlusive events. Reporting events based on a frequency threshold, lack of sufficient follow-up, attempts at causality attribution, and the primary focus on molecular response may all have played an additional role. Considering the increasing rate of arterio-occlusive events over time, the termination of many trials after only 5 years prevents full assessment of the impact of these events. A comprehensive evaluation of TKI adverse effects using uniform Medical Dictionary for Regulatory Activities terms and comprehensive adjudication of these events may be helpful in better assessing the real risk for patients with each TKI. Future clinical trials should use a uniform and comprehensive approach to reporting adverse events without attempting to assign causality to the study drug.
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Affiliation(s)
| | - Jorge Cortes
- Georgia Cancer Center at Augusta University, Augusta, GA
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Yan G, Han Z, Kwon Y, Jousma J, Nukala SB, Prosser BL, Du X, Pinho S, Ong SB, Lee WH, Ong SG. Integrated Stress Response Potentiates Ponatinib-Induced Cardiotoxicity. Circ Res 2024; 134:482-501. [PMID: 38323474 PMCID: PMC10940206 DOI: 10.1161/circresaha.123.323683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/22/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Mitochondrial dysfunction is a primary driver of cardiac contractile failure; yet, the cross talk between mitochondrial energetics and signaling regulation remains obscure. Ponatinib, a tyrosine kinase inhibitor used to treat chronic myeloid leukemia, is among the most cardiotoxic tyrosine kinase inhibitors and causes mitochondrial dysfunction. Whether ponatinib-induced mitochondrial dysfunction triggers the integrated stress response (ISR) to induce ponatinib-induced cardiotoxicity remains to be determined. METHODS Using human induced pluripotent stem cells-derived cardiomyocytes and a recently developed mouse model of ponatinib-induced cardiotoxicity, we performed proteomic analysis, molecular and biochemical assays to investigate the relationship between ponatinib-induced mitochondrial stress and ISR and their role in promoting ponatinib-induced cardiotoxicity. RESULTS Proteomic analysis revealed that ponatinib activated the ISR in cardiac cells. We identified GCN2 (general control nonderepressible 2) as the eIF2α (eukaryotic translation initiation factor 2α) kinase responsible for relaying mitochondrial stress signals to trigger the primary ISR effector-ATF4 (activating transcription factor 4), upon ponatinib exposure. Mechanistically, ponatinib treatment exerted inhibitory effects on ATP synthase activity and reduced its expression levels resulting in ATP deficits. Perturbed mitochondrial function resulting in ATP deficits then acts as a trigger of GCN2-mediated ISR activation, effects that were negated by nicotinamide mononucleotide, an NAD+ precursor, supplementation. Genetic inhibition of ATP synthase also activated GCN2. Interestingly, we showed that the decreased abundance of ATP also facilitated direct binding of ponatinib to GCN2, unexpectedly causing its activation most likely because of a conformational change in its structure. Importantly, administering an ISR inhibitor protected human induced pluripotent stem cell-derived cardiomyocytes against ponatinib. Ponatinib-treated mice also exhibited reduced cardiac function, effects that were attenuated upon systemic ISRIB administration. Importantly, ISRIB does not affect the antitumor effects of ponatinib in vitro. CONCLUSIONS Neutralizing ISR hyperactivation could prevent or reverse ponatinib-induced cardiotoxicity. The findings that compromised ATP production potentiates GCN2-mediated ISR activation have broad implications across various cardiac diseases. Our results also highlight an unanticipated role of ponatinib in causing direct activation of a kinase target despite its role as an ATP-competitive kinase inhibitor.
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Affiliation(s)
- Gege Yan
- Department of Pharmacology & Regenerative Medicine, University of Illinois College of Medicine, Chicago, USA
| | - Zhenbo Han
- Department of Pharmacology & Regenerative Medicine, University of Illinois College of Medicine, Chicago, USA
| | - Youjeong Kwon
- Department of Pharmacology & Regenerative Medicine, University of Illinois College of Medicine, Chicago, USA
| | - Jordan Jousma
- Department of Pharmacology & Regenerative Medicine, University of Illinois College of Medicine, Chicago, USA
| | - Sarath Babu Nukala
- Department of Pharmacology & Regenerative Medicine, University of Illinois College of Medicine, Chicago, USA
| | - Benjamin L Prosser
- Department of Physiology, Pennsylvania Muscle Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xiaoping Du
- Department of Pharmacology & Regenerative Medicine, University of Illinois College of Medicine, Chicago, USA
| | - Sandra Pinho
- Department of Pharmacology & Regenerative Medicine, University of Illinois College of Medicine, Chicago, USA
| | - Sang-Bing Ong
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong (CUHK), Hong Kong SAR, China
- Centre for Cardiovascular Genomics and Medicine (CCGM), Lui Che Woo Institute of Innovative Medicine, CUHK, Hong Kong SAR, China
- Hong Kong Hub of Pediatric Excellence (HK HOPE), Hong Kong Children’s Hospital (HKCH), Kowloon Bay, Hong Kong SAR, China
- Kunming Institute of Zoology – The Chinese University of Hong Kong (KIZ-CUHK) Joint Laboratory of Bioresources and Molecular Research of Common Diseases, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, China
- Neural, Vascular, and Metabolic Biology Thematic Research Program, School of Biomedical Sciences (SBS), Chinese University of Hong Kong (CUHK), Hong Kong SAR, China
| | - Won Hee Lee
- Department of Basic Medical Sciences, University of Arizona College of Medicine, Phoenix, USA
| | - Sang-Ging Ong
- Department of Pharmacology & Regenerative Medicine, University of Illinois College of Medicine, Chicago, USA
- Division of Cardiology, Department of Medicine, University of Illinois College of Medicine, Chicago, USA
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Van den Eeckhaut L, Hannon H, Schurgers M, Monsaert E, Claes K. Gemcitabine-induced thrombotic microangiopathy treated with eculizumab: a case report. J Gastrointest Oncol 2022; 13:3314-3320. [PMID: 36636054 PMCID: PMC9830318 DOI: 10.21037/jgo-22-509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/21/2022] [Indexed: 11/29/2022] Open
Abstract
Background Gemcitabine is a broadly used chemotherapeutic agent that can cause a rare but life-threatening complication called thrombotic microangiopathy (TMA). Early recognition is crucial as therapy options are limited. Case Description We report the case of a 46-year-old patient with pancreatic adenocarcinoma who presented with severe anemia and thrombocytopenia as well as acute kidney injury. A diagnosis of gemcitabine-induced TMA was made. He became rapidly transfusion and dialysis dependent. Despite discontinuation of gemcitabine and treatment with high-dose corticotherapy as well as plasmapheresis, no improvement in both renal and hematological parameters was seen. Treatment with eculizumab was initiated. One week after the first administration, the patient no longer required packed cells nor platelet transfusions and one month later, dialysis could be discontinued. After five doses, treatment with eculizumab was stopped. Four months later, his serum creatinine was 1 mg/dL. Conclusions This case report illustrates the promising beneficial effects of eculizumab in gemcitabine-induced TMA, both regarding transfusion dependence as well as improvement in renal function, thereby allowing further therapy options in patients with an active malignancy.
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Affiliation(s)
| | - Heidi Hannon
- Department of Nephrology, AZ Maria Middelares, Ghent, Belgium
| | - Marie Schurgers
- Department of Nephrology, AZ Maria Middelares, Ghent, Belgium
| | - Els Monsaert
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
| | - Kathleen Claes
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Leuven, Belgium.,Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Balanescu DV, Bloomingdale R, Donisan T, Yang EH, Parwani P, Iliescu C, Herrmann J, Hanson I. Mechanisms of Myocardial Ischemia in Cancer Patients: A State-of-the-Art Review of Obstructive Versus Non-Obstructive Causes. Rev Cardiovasc Med 2022; 23:227. [PMID: 39076910 PMCID: PMC11266791 DOI: 10.31083/j.rcm2307227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/10/2022] [Accepted: 05/16/2022] [Indexed: 07/31/2024] Open
Abstract
In patients with cancer, myocardial infarction (MI) has distinct features and mechanisms compared to the non-oncology population. Triggers of myocardial ischemia specific to the oncology population have been increasingly identified. Coronary plaque disruption, coronary vasospasm, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary oxygen supply-demand mismatch are all causes of MI that have been shown to have specific triggers related to either the treatments or complications of cancer. MI can occur in the presence or absence of atherosclerotic coronary artery disease (CAD). MI with nonobstructive CAD (MINOCA) is a heterogeneous syndrome that has distinct pathophysiology and different epidemiology from MI with significant CAD (MI-CAD). Recognition and differentiation of MI-CAD and MINOCA is essential in the oncology population, due to unique etiology and impact on diagnosis, management, and overall outcomes. There are currently no reports in the literature concerning MINOCA as a unified syndrome in oncology patients. The purpose of this review is to analyze the literature for studies related to known triggers of myocardial ischemia in cancer patients, with a focus on MINOCA. We propose that certain cancer treatments can induce MINOCA-like states, and further research is warranted to investigate mechanisms that may be unique to certain cancer states and types of treatment.
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Affiliation(s)
- Dinu V. Balanescu
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI 48073, USA
| | | | - Teodora Donisan
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI 48073, USA
| | - Eric H. Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA
| | - Purvi Parwani
- Department of Cardiology, Loma Linda University International Heart Institute, Loma Linda, CA 92354, USA
| | - Cezar Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55903, USA
| | - Ivan Hanson
- Department of Cardiology, Beaumont Hospital, Royal Oak, MI 48073, USA
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Lipton JH, Brümmendorf TH, Gambacorti-Passerini C, Garcia-Gutiérrez V, Deininger MW, Cortes JE. Long-term safety review of tyrosine kinase inhibitors in chronic myeloid leukemia - What to look for when treatment-free remission is not an option. Blood Rev 2022; 56:100968. [DOI: 10.1016/j.blre.2022.100968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 12/14/2022]
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Wu MD, Moslehi JJ, Lindner JR. Arterial Thrombotic Complications of Tyrosine Kinase Inhibitors. Arterioscler Thromb Vasc Biol 2021; 41:3-10. [PMID: 33275447 PMCID: PMC7770029 DOI: 10.1161/atvbaha.120.314694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abnormal expression or function of several classes of kinases contribute to the development of many types of solid and hematologic malignancies. TKs (tyrosine kinases) in particular play a role in tumor growth, metastasis, neovascularization, suppression of immune surveillance, and drug resistance. TKIs (tyrosine kinase inhibitors) targeted to TKs such as BCR-ABL1, VEGF receptors, PDGF receptors, have transformed therapy of certain forms of cancer by providing excellent efficacy with relatively low adverse event rates. Yet some of these agents have been associated with high rates of vascular events, presumably from prothrombotic complications that result in myocardial infarction, stroke, and critical limb ischemia. This review describes the scope of the problem evidenced by clinical experience with some of the most commonly used TKIs, with a focus on TKIs targeted to the BCR-ABL1 (breakpoint cluster region-Abelson 1) translocation. We also discuss the potential mechanisms responsible for arterial thrombotic complications that could lead to mitigation strategies or unique TK targeting strategies to reduce adverse event rates without compromising efficacy.
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Affiliation(s)
- Melinda D Wu
- Knight Cardiovascular Institute (M.D.W., J.R.L.), Department of Pediatrics, Oregon Health & Science University, Portland
- Papé Family Pediatric Research Institute (M.D.W.), Department of Pediatrics, Oregon Health & Science University, Portland
| | - Javid J Moslehi
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.J.M.)
| | - Jonathan R Lindner
- Knight Cardiovascular Institute (M.D.W., J.R.L.), Department of Pediatrics, Oregon Health & Science University, Portland
- Oregon National Primate Research Center, Portland (J.R.L.)
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