Cancer therapy and cardiotoxicity: the need of serial Doppler echocardiography

Development and Validation of a Diagnostic Nomogram to Predict the Anthracycline-Induced Early Cardiotoxicity in Children with Hematological Tumors

This study aimed to establish and validate an effective nomogram to predict the risk of cardiotoxicity in children after each anthracycline treatment. According to the inclusion and exclusion criteria, the eligible children were randomly divided into the training cohort (75%) and the validation cohort (25%). Least absolute shrinkage and selection operator (LASSO) regression was used to select the predictors and a nomogram was developed. Then, concordance index (C-index), the area under the curve (AUC), Hosmer-Lemeshow (H-L) test, and decision curve analysis (DCA) were employed to evaluate the performance and clinical utility of nomogram. Internal validation was processed to inspect the stability of the model. A total of 796 eligible children were included in this study and divided into a training set (n = 597) and a validation set (n = 199). LASSO regression analysis revealed that cumulative anthracycline dose, ejection fractions, NT-proBNP, and diastolic dysfunction were effective predictors of cardiotoxicity. The nomogram was established based on these variables. The C-index and the AUC of the predicting nomogram were 0.818 in the training cohort and 0.773 in the validation cohort, suggesting that the nomogram had good discrimination. The calibration curve of the nomogram presented no significant deviation from the reference line, and the P-value of the H-L test was 0.283, implying a preferable degree of calibration. The threshold of DCA also reflects that the nomogram is clinically useful. A nomogram was developed to predict anthracycline chemotherapy-induced cardiotoxicity in children with hematological tumors. The nomogram has a good prediction effect and can provide a reference for clinicians' diagnosis and treatment.

Evaluation of cardioprotective effects of carvedilol in dogs receiving doxorubicin chemotherapy: A prospective, randomized, double-blind, placebo controlled pilot study

The aim of this pilot study was to evaluate the cardioprotective effects of carvedilol in dogs receiving doxorubicin chemotherapy and provide suggestions to future studies based on results and limitations of our study. Thirteen dogs were randomized into two experimental groups: 6 dogs in carvedilol group and 7 dogs in placebo group. In carvedilol group, 0.39 mg/kg ± 0.04 twice-daily oral carvedilol was started on the day of the first doxorubicin treatment and continued throughout the chemotherapy protocol until the final cardiological evaluation. Cardiological evaluations were performed before the first doxorubicin administration and then 10 to 15 days after each subsequent dose. Troponin I and oxidative stress tests were performed with serum collected from dogs at the initial and final cardiological evaluation. Carvedilol produced some echocardiographic and electrocardiographic changes (reduced E velocity and E/IVRT ratio, as well reduced heart rate and increased PR and QT interval) due to its beta-block effect. In placebo group Doppler study showed a significant increase in mitral flow deceleration time (EDT), as well increased amplitude of the S wave in the right, and R wave in the left, precordial chest leads. There were significant difference in the EDT, E/IVRT and A' velocity, as well heart rate, PR interval and R wave in V4/CV6LU precordial chest lead between groups. In conclusion, some indexes of diastolic function and in precordial chest leads were less affected by doxorubicin in carvedilol than in control group. This suggests that carvedilol may have a beneficial effect in canine cancer patients receiving doxorubicin.

Cardiotoxicity - the first cause of morbidity and mortality in pediatric patients survivors of acute lymphoblastic leukemia

Acute lymphoblastic leukemia is the most common hematological malignancy at pediatric age. Cardiotoxicity holds the first place among the causes of morbidity and mortality in these patients. Anthracyclines are cytostatic drugs frequently associated with cardiotoxicity. Early diagnosis of cardiac impairment during the treatment of pediatric patients is extremely important, both for modulating future chemotherapy and for administering cardioprotective agents. Long term monitoring after chemotherapy helps to identify the risk of late cardiotoxicity among cancer survivors. There are several biomarkers, already in use or still under study, which may represent an operator-independent alternative for echocardiography in the diagnosis of cardiotoxicity. In case of cardiac damage, the clinician has options for treating or limiting the progression, either with the use of already approved agents, such as Dexrazoxane, or by administrating other cardioprotective drugs. International experts are still attempting to establish the best algorithm for early detection of cardiotoxicity, as well as the most efficient treatment plan in case of already existing myocardial damage in these patients. We present a review on treatment-related cardiotoxicity, including mechanisms of development, useful biomarkers and treatment options, after carefully analyzing specialty literature.

Valvular Damage

Valvular heart diseases (VHD) may be observed in patients with cancer for several reasons, including preexisting valve lesions, radiotherapy, infective endocarditis, and secondary to the left ventricle dysfunction. The incidence of VHD is especially in younger survivors treated with thoracic radiation therapy for certain malignancies, such as Hodgkin's lymphoma and breast cancer. The mechanism of radiation-induced damage to heart valves is not clear and includes diffuse fibrocalcific thickening of the valve. VHD is commonly diagnosed after a long latent period, in the context of clinical symptoms, or suspected on the basis of a new murmur. The evaluation includes identification of anatomical valve abnormalities, valve dysfunction, and assessing the functional consequences of valve dysfunction on the ventricles. Echocardiography is the optimal imaging technique for diagnostic and therapeutic management. Cardiovascular magnetic resonance and computed tomography (CT) may be used to assess the severity of VHD, but cardiac CT is mainly useful for detecting extensive calcifications of the ascending aorta. Patients exposed to mediastinal radiotherapy and minimal valve dysfunction require follow-up of 2–3 years, with moderate valve disease yearly, with severe, should be assessed for valve surgery.

Use of echocardiography to monitor myocardial damage during anthracycline chemotherapy

BACKGROUND

Anthracycline-related cardiotoxicity has a poor prognosis; therefore, early detection of any change in LV function is critical.

OBJECTIVE

The aim of this study was to evaluate the two-dimensional speckle tracking technique for the early detection of cardiac toxicity after low-dose anthracycline chemotherapy in the Chinese population.

METHODS

Forty breast cancer patients were treated by chemotherapy using anthracycline for 4-6 cycles. Patients were examined by echocardiography before chemotherapy (T0) and after the second (T2), fourth (T4), and sixth (T6) cycle. LV ejection fraction (LVEF), LV global longitudinal strain (GLS) and endocardium, mid-myocardium, and epicardium global longitudinal strain (GLS-Endo, GLS-Mid, and GLS-Epi). Additionally, global circumferential strain (GCS), RV global longitudinal strain (RVGLS), and LA global longitudinal strain (LAGLS) were evaluated.

RESULTS

Left ventricular ejection fraction was significantly reduced at T4 (P < 0.05). Compared with T0, GLS, GLS-Endo, GLS-Mid, and GLS-Epi were significantly reduced at T2, T4, and T6 (P < 0.05 for all), the apical septum wall (AS) was also reduced significantly at T2 (P < 0.05), and the apical anterior wall (AA) and the basal anterior wall (BA) longitudinal strains were significantly reduced at T4 (P < 0.05). GCS, RVGLS, and LAGLS were not significantly changed after treatment (P > 0.05).

CONCLUSIONS

LV stratified strains and strain of the segments supplied by the left anterior descending coronary artery are more sensitive to the cardiac toxicity of anthracycline.

The Use of Imaging in the Prediction and Assessment of Cancer Treatment Toxicity

Multimodal imaging is commonly used in the management of patients with cancer. Imaging plays pivotal roles in the diagnosis, initial staging, treatment response assessment, restaging after treatment and the prognosis of many cancers. Indeed, it is difficult to imagine modern precision cancer care without the use of multimodal molecular imaging, which is advancing at a rapid pace with innovative developments in imaging sciences and an improved understanding of the complex biology of cancer. Cancer therapy often leads to undesirable toxicity, which can range from an asymptomatic subclinical state to severe end organ damage and even death. Imaging is helpful in the portrayal of the unwanted effects of cancer therapy and may assist with optimal clinical decision-making, clinical management, and overall improvements in the outcomes and quality of life for patients.

Advanced Echocardiographic Techniques in Detection of Cardiotoxicity

OPINION STATEMENT

As advancements are made in cancer treatment, there is an increasing recognition of the cardiotoxic potential of chemotherapies and the need to monitor for the development of cardiac dysfunction in survivors. Echocardiography is the cornerstone of cardiac imaging and provides a feasible and non-invasive method to assess cardiac dysfunction in patients with cancer. In recent years, there has been increasing research in echocardiographic techniques to improve diagnosis of cardiotoxicity, including a more accurate assessment of the left ventricular function and the detection of subclinical disease. These specialized techniques include stress and contrast echocardiography, three-dimensional echocardiography, diastolic dysfunction, tissue Doppler imaging, and strain parameters.

Prospective evaluation of Doppler echocardiography, tissue Doppler imaging and biomarkers measurement for the detection of doxorubicin-induced cardiotoxicity in dogs: A pilot study

The purpose of this pilot study was to evaluate the usefulness of selected echocardiographic parameters, NT-proBNP and cardiac troponin I (cTnI) in the detection of cardiotoxicity in dogs treated with doxorubicin for various malignancies. Echocardiographic studies and biomarker measurements were performed before each administration of doxorubicin, then 1 and 3 months after completion of therapy. Thirteen dogs were included, with a total cumulative dose of doxorubicin ranging from 30 to 150 mg/m(2). E/A ratio significantly decreased during doxorubicin administration (p=0.047). cTnI level was also significantly affected by treatment (p=0.046), increasing above normal at least at one time point in 11 of 13 dogs. The results of this pilot study suggest that monitoring of left ventricular diastolic function and cTnI level measurement might be useful in the early detection of cardiotoxic signs of doxorubicin therapy in dogs.

Outcomes of Cancer Patients Undergoing Percutaneous Pericardiocentesis for Pericardial Effusion

BACKGROUND

Pericardial effusion (PE) is common in cancer patients, but the optimal therapeutic approach is not well defined. Percutaneous pericardiocentesis is less invasive than surgery, but its long-term effectiveness and safety have not been well documented.

OBJECTIVES

The goal of this study was to evaluate outcomes of cancer patients undergoing percutaneous pericardiocentesis for PE and assess the procedure's safety in patients with thrombocytopenia.

METHODS

Cancer patients who underwent percutaneous pericardiocentesis for PE between November 2009 and October 2014 at the MD Anderson Cancer Center were included. Procedure-related complications, effusion recurrence rate, and overall survival were analyzed.

RESULTS

Of 1,645 cancer patients referred for PE, 212 (13%) underwent percutaneous pericardiocentesis. The procedure was successful in 99% of the cases, and there were no procedure-related deaths. Four patients had major procedure-related bleeding that did not vary by platelet count <50,000/μl or ≥50,000/μl (p = 0.1281). Patients with catheter drainage for 3 to 5 days had the lowest recurrence rate (10%). Median overall survival was 143 days; older age (i.e., >65 years), lung cancer, platelet count <20,000/μl, and malignant pericardial fluid were independently associated with poor prognosis. Lung cancer patients with proven malignant effusions had a significantly shorter median 1-year survival compared with those with nonmalignant effusions (16.2% vs. 49.0%, respectively; log-rank test p = 0.0101). A similar difference in 1-year survival was not observed in patients with breast cancer (40.2% vs. 40.0%; log-rank test p = 0.4170).

CONCLUSIONS

Percutaneous pericardiocentesis with extended catheter drainage was safe and effective as the primary treatment for PE in cancer patients, including in those with thrombocytopenia. Malignant PE significantly shortened the survival outcome of patients with lung cancer but not those with breast cancer.

Assessing anthracycline-treated childhood cancer survivors with advanced stress echocardiography

BACKGROUND

Surveillance for anthracycline cardiotoxicity in cancer survivors typically utilizes resting M-mode and two-dimensional echocardiography, which are insensitive to detection of subtle myocardial changes. We examined childhood cancer survivors treated with anthracyclines during exercise using various echocardiography techniques to investigate if these tools can better detect subclinical cardiac dysfunction.

PROCEDURE

We recruited asymptomatic survivors at least five years post treatment. Echocardiography was performed at rest and at termination of exercise utilizing tissue Doppler techniques and strain rate imaging.

RESULTS

Eighty participants were characterized by cardiotoxicity risk status (high [12], moderate [23], low [24], no risk [21]) as defined by the Children's Oncology Group Long Term Follow-Up Guidelines v3.0. The high-risk group had a higher resting heart rate than controls (100 vs. 88 bpm [P for trend = 0.049]). Peak aerobic capacity in all groups was similar. Compared to controls at rest, the high-risk group had evidence of diastolic dysfunction with lower E/A ratios (1.4 vs. 2.0, P = 0.008) and higher septal early diastolic velocities (E/E') of 11.7 versus 9.9 (P = 0.165). With exercise, this difference resolved and myocardial contractile reserve was preserved.

CONCLUSIONS

Asymptomatic, pediatric cancer survivors at high-risk for anthracycline cardiotoxicity have some evidence of diastolic filling abnormalities at rest. With exercise, they augment their systolic and diastolic function to achieve normal maximal aerobic capacity suggesting they are able to compensate for mild cardiac dysfunction in the early years after exposure. Additionally, findings suggest that routine exercise echocardiography may not be a useful surveillance tool to assess anthracycline cardiotoxicity.

Image-guided radiotherapy for cardiac sparing in patients with left-sided breast cancer

Patients with left-sided breast cancer are at risk of cardiac toxicity because of cardiac irradiation during radiotherapy with the conventional 3-dimensional conformal radiotherapy technique. In addition, many patients may receive chemotherapy prior to radiation, which may damage the myocardium and may increase the potential for late cardiac complications. New radiotherapy techniques such as intensity-modulated radiotherapy (IMRT) may decrease the risk of cardiac toxicity because of the steep dose gradient limiting the volume of the heart irradiated to a high dose. Image-guided radiotherapy (IGRT) is a new technique of IMRT delivery with daily imaging, which may further reduce excessive cardiac irradiation. Preliminary results of IGRT for cardiac sparing in patients with left-sided breast cancer are promising and need to be investigated in future prospective clinical studies.

Noninvasive imaging of cardiovascular injury related to the treatment of cancer

The introduction of multiple treatments for cancer, including chemotherapeutic agents and radiation therapy, has significantly reduced cancer-related morbidity and mortality. However, these therapies can promote a variety of toxicities, among the most severe being the ones involving the cardiovascular system. Currently, for many surviving cancer patients, cardiovascular (CV) events represent the primary cause of morbidity and mortality. Recent data suggest that CV injury occurs early during cancer treatment, creating a substrate for subsequent cardiovascular events. Researchers have investigated the utility of noninvasive imaging strategies to detect the presence of CV injury during and after completion of cancer treatment because it starts early during cancer therapy, often preceding the development of chemotherapy or cancer therapeutics related cardiac dysfunction. In this State-of-the-Art Paper, we review the utility of current clinical and investigative CV noninvasive modalities for the identification and characterization of cancer treatment-related CV toxicity.

Radiotherapy and anthracyclines - cardiovascular toxicity

The subject of this paper is to analyze the impact of radiotherapy and anthracyclines on the cardiovascular system, based on a survey of contemporary literature. Currently, high efficiency of anticancer therapies has increased the rate of survival in patients treated for cancer. It should be emphasized, however, that these treatments damage not only the affected but also the healthy tissue. Consequently, with the increase of survival rate in these patients, the number of patients with complaints regarding numerous organs and systems also increases as a result of earlier treatment. Thus, during the first decade of the 21^st century, a number of concerns about the relationship between cancer treatment and dysfunction of the cardiovascular system were resolved. Anthracyclines, as well as radiotherapy, are capable of damaging the cardiovascular system, both at the central level, by the deterioration of cardiac function, and at peripheral levels, by increasing the hemodynamic and thrombotic changes.

Anthracycline-induced cardiotoxicity: prospective cohort study from Pakistan

OBJECTIVES

To identify anthracycline-induced acute (within 1 month) and early-onset chronic progressive (within 1 year) cardiotoxicity in children younger than 16 years of age with childhood malignancies at a tertiary care centre of Pakistan.

DESIGN

Prospective cohort study.

SETTING

Aga Khan University, Karachi, Pakistan.

PARTICIPANTS

110 children (aged 1 month-16 years).

INTERVENTION

Anthracycline (doxorubicin and/or daunorubicin).

OUTCOME MEASUREMENTS

All children who received anthracycline as chemotherapy and three echocardiographic evaluations (baseline, 1 month and 1 year) between July 2010 and June 2012 were prospectively analysed for cardiac dysfunction. Statistical analysis including systolic and diastolic functions at baseline, 1 month and 1 year was carried out by repeated measures analysis of variance.

RESULTS

Mean age was 74±44 months and 75 (68.2%) were males. Acute lymphoblastic leukaemia was seen in 70 (64%) patients. Doxorubicin alone was used in 59 (54%) and combination therapy was used in 35 (32%). A cumulative dose of anthracycline <300 mg/m(2) was used in 95 (86%). Fifteen (14%) children developed cardiac dysfunction within a month and 28 (25%) children within a year. Of these 10/15 (66.6%) and 12/28 (43%) had isolated diastolic dysfunction, respectively, while 5/15 (33.3%) and 16/28 (57%) had combined systolic and diastolic dysfunction. Seven (6.4%) patients expired due to severe cardiac dysfunction. Eight of 59 (13.5%) children showed dose-related cardiotoxicity (p=<0.001). Cardiotoxicity was also high when the combination of doxorubicin and daunorubicin was used (p=0.004).

CONCLUSIONS

Incidence of anthracycline-induced cardiotoxicity is high. Long-term follow-up is essential to diagnose its late manifestations.

Temporal changes in standard and tissue Doppler imaging echocardiographic parameters after anthracycline chemotherapy in women with breast cancer

Anthracyclines are established cardiotoxic agents; however, the exact extent and time course of such cardiotoxicity has not been appraised in detail. We aimed to exploit serial measurements of standard and tissue Doppler imaging (TDI) echocardiographic parameters collected in a prospective clinical trial to clarify the outlook of cardiac function during and long after anthracycline chemotherapy. Women enrolled in a randomized trial focusing on liposomal doxorubicin-based chemotherapy for breast cancer and providing ≥4 separate echocardiographic assessments were included. Repeat-measure nonparametric analyses were used to appraise changes over time in the standard and tissue Doppler imaging echocardiographic parameters. A total of 39 patients with serial imaging evaluations were enrolled. Significant temporal changes were found for the left ventricular ejection fraction and diastolic parameters, despite different temporal trends. Specifically, the left ventricular ejection fraction exhibited a V-shaped trend, decreasing initially from 63% to 61% but then recovering to 64% (p <0.001), with a similar trend in the TDI E/Em ratio (p = 0.011). In contrast, persistent impairments typical of an L-shaped trend were found for the E wave (p = 0.006), TDI lateral Em wave (p = 0.001), and TDI septal Em wave (p = 0.001). In conclusion, subclinical temporal changes in the standard and TDI echocardiographic parameters after anthracycline chemotherapy showed a distinctive pattern of transient impairment followed by full recovery of the left ventricular ejection fraction versus a persistent impairment of the diastolic parameters, which must be taken into account in the everyday treatment of such patients.

Using cardiac biomarkers and treating cardiotoxicity in cancer

Cardiotoxicity is a frequent and serious adverse effect of both conventional and novel anticancer treatments, affecting patient survival and quality of life. The current standard for cardiac monitoring during cancer therapy, mainly based on left ventricular ejection fraction assessment, detects myocardial damage only when a functional impairment has already occurred, not allowing for early preventive strategies. Measurement of cardiospecific biomarkers has proven to have higher prognostic value than imaging modalities. In particular, cardiac troponin elevation during chemotherapy allows the identification of patients who are more prone to develop myocardial dysfunction and cardiac events during follow-up. In these patients, the use of an angiotensin-converting enzyme inhibitor such as enalapril has shown to be effective in improving clinical outcome, giving the chance for a cardioprotective strategy in a selected population. Once left ventricular dysfunction occurs, heart failure therapies currently used for other forms of left ventricular dysfunction, particularly angiotensin-converting enzyme inhibitors and β-blockers, seem to be effective. However, their use in cancer patients is still undervalued.

Long term follow-up report of cardiac toxicity in patients with multiple myeloma treated with tandem autologous hematopoietic stem cell transplantation

Background

Tandem autologous hematopoietic stem cell transplantation (ta-HSCT) is a standard treatment for multiple myeloma (MM). Patients receive a high-dose cyclophosphamide (CY), followed by two myeloablative cycles of melphalan (MEL). There are scarce data about long term cardiotoxicity.

Patients and methods.

We studied 12 patients (62.25 ± 8.55 years) six years after the completion of MM treatment with ta-HCST. Late cardiotoxic effects were evaluated clinically and echocardiographically.

Results

None of the patients developed clinical signs of heart failure, all were in sinus rhythm and NT-pro BNP concentration was elevated (778 ± 902.76 pg/mL). The left ventricular (LV) size remained normal. The LV ejection fraction did not decrease (73.75 ± 5.67%, 69.27 ± 6.13%, p = NS). The LV diastolic function parameters (E, A, ratio E/A and A/a) did not change significantly. In tissue Doppler parameters we observed a nonsignificant decrease in E_m (10.26 ± 2.63 cm/s, 7.57 ± 1.43 cm/s) and S_m velocities (8.7 ± 0.87 cm/s, 7.14 ± 1.17 cm/s, p = NS). The E/E_m values were in an abnormal range (8.66 ± 1.05, 10.55 ± 2.03).

Conclusions

The treatment of MM with ta-HSCT, during which patients receive a high dose CY followed by two myeloablative cycles of MEL, causes mild, chronic, partially reversible and clinically silent cardiotoxic side-effects. However, ta-HSCT in patients with MM is a safe regarding cardiotoxic side effects, but, because of increasing life expectancy needs long term attention.

Chemotherapy-Induced Cardiotoxicity: Subclinical Cardiac Dysfunction Evidence Using Speckle Tracking Echocardiography

Objectives:

In our study, we aimed to identify early markers of cardiac dysfunction in patients treated with mitoxantrone. We also looked at cardiac functional changes during therapy by analyzing longitudinal deformation and by measuring left ventricular (LV) and left atrial (LA) global strain.

Materials and Methods:

LA and LV global longitudinal strain were analyzed in 20 patients affected by multiple sclerosis and treated with mitoxantrone. Patients underwent echocardiography before treatment, after every drug administration during the 12-months treatment period, and finally after 6 and 12 months of drug discontinuation.

Results:

Compared with baseline values, patients showed a significant reduction of both LA and LV longitudinal global strain at the end of treatment with mitoxantrone (LA_GS% T10 vs. T0 values: 15,2 ± 12,5 vs. 20,2 ± 11,1; LV_GS%: ─16,4 ± 2,5 vs. ─17,4 ± 3,8). Strain reduction reverted after treatment discontinuation (LA_GS% FU vs. T0 values: 20,4 ± 15,7 vs. 20,2 ± 11,1; LV_GS%: ─17,3 ± 3,3 vs. ─17,4 ± 3,8).

Conclusions:

Impairment of longitudinal deformation during mitoxantrone therapy may indicate a dysfunction related to early myocardial damage. These findings appear to be reversible after treatment discontinuation.

Capecitabine-induced cardiotoxicity: case report and review of the literature

Capecitabine, an oral prodrug of 5-fluorouracil (5fu), has been integrated into the management of multiple cancer types because of convenience of administration and efficacy comparable with 5fu. Cardiotoxicity induced by 5fu—in particular angina—has been well described in the literature, but reports of adverse cardiac events with capecitabine are also emerging. The mechanism underlying 5fu cardiotoxicity has long been thought to result from coronary vasospasm, but animal-model studies and patient echocardiographic findings both suggest a cardiomyopathic picture. Although 5fu cardiotoxicity is often reversible and can be managed supportively, presentations that are more severe—including arrhythmias, acute ischemic events, and cardiogenic shock—have been documented. In this report, we describe the case of a patient who ultimately required a pacemaker after developing symptomatic bradycardia and sinus arrest while receiving capecitabine for colon cancer.

Review of cardiotoxicity in pediatric cancer patients: during and after therapy

With the improvement in survival from childhood cancer, late effects of therapy are becoming more apparent. Cardiac disease, one of these late effects, has a significant impact on the life of survivors of childhood cancers. Most survivors are followed by primary care doctors and adult subspecialists after they have graduated from pediatric centers. Since much of the cardiac toxicity of therapy occurs years off of therapy, it is important for these physicians to be aware of how to monitor survivors for the development of cardiac toxicities. In this paper we will discuss the incidence of cardiac disease during treatment and in survivors, what treatment modalities contribute to its development and modalities utilized to screen for cardiac disease. Recommendations for posttherapy monitoring will be emphasized.

Impact of treatment-related cardiac toxicity on lymphoma survivors: an institutional approach for risk reduction and management

Despite improvements in treatment and overall survival rates, survivors of lymphoma may have long-term and late effects. Given the immense risk for cardiac disease after treatment for Hodgkin lymphoma and non-Hodgkin lymphoma, healthcare providers should focus on prevention of secondary adverse effects. The Dana-Farber Cancer Institute has been working to develop guidelines to address the cardiotoxicities that impact the lymphoma survivor population.

Cardiovascular effects of systemic cancer treatment

Many methods of systemic anticancer treatment have detrimental effects on the cardiovascular system, thus limiting the possibility of further therapy, worsening patients' quality of life and increasing mortality. The best recognized and most clinically relevant is the cardiotoxicity of anthracyclines. Other cytotoxic drugs associated with significant risk of cardiovascular complications include alkylating agents, 5-fluorouracil and paclitaxel. Cardiovascular adverse effects are also associated with the use of targeted therapies, such as trastuzumab, bevacizumab and tyrosine kinase inhibitors, and some of the drugs used in the treatment of hematological malignancies, such as all-trans-retinoic acid and arsenic trioxide. The most serious cardiac complication of anticancer therapy is congestive heart failure, associated predominantly with the use of anthracyclines, trastuzumab and high-dose cyclophosphamide. Myocardial ischemia is mainly caused by antimetabolite and interferon alpha treatment. Other adverse effects may include hypotension, hypertension, arrhythmias and conduction disorders, edema, pericarditis and thrombo-embolic complications. The aim of this review is to summarize and critically analyze the available evidence on the cardiovascular toxicity of systemic anticancer therapies, with particular attention to the recently recognized adverse effects of targeted therapies.

Anticancer therapy induced cardiotoxicity: review of the literature

Innovative anticancer strategies have contributed to an improved survival of patients suffering from malignancies, and in some cases, have turned cancer into a chronic disease. Therefore, the early and particularly late onsets of adverse cardiovascular effects of systemic anticancer treatments are of increasing interest. Among a rapidly increasing variety of anticancer drugs, the anthracyclines and the monoclonal antibody, trastuzumab, are the agents with a well-known cardiotoxicity. The diagnostic work-up, the cardiotoxic risk of anthracyclines and trastuzumab, and additionally, cardiotoxicity as a risk factor of a multimodal therapeutic approach in breast cancer patients is discussed in this study.

The role of echocardiography in the assessment of cardiac function in weightlessness-Our experience during parabolic flights

Parabolic flight (PF) elicits changes in hydrostatic pressure gradients, resulting in increase (at 0Gz) or decrease (at 1.8Gz) in cardiac preload. The magnitude of these changes on left ventricular (LV) and atrial (LA) volumes, as well as on myocardial velocities, strain and strain rates, is largely unknown. Using real-time 3D (RT3DE) and Doppler tissue echocardiographic imaging (DTI) during PF in normal subjects in standing position, we showed that both LV and LA volumes were decreased at 1.8Gz and increased at 0Gz by about 20% and 40%, respectively. Previous 2D or M-mode studies underestimated such changes. Also, preload dependence was confirmed for systolic and diastolic velocities, and peak systolic strain, while strain rates were preload independent, probably reflecting intrinsic myocardial properties. Low body negative pressure at -50mmHg applied during 0Gz was effective in restoring 1Gz levels. RT3DE and DTI during PF are feasible, allowing the evaluation of the cardiac function under different loading conditions.

Evaluation of sub-acute changes in cardiac function after cisplatin-based combination chemotherapy for testicular cancer

Long-term cardiovascular morbidity is increasingly observed in chemotherapy-treated testicular cancer survivors, but little is known of early sub-clinical changes in cardiac function. We prospectively evaluated cardiac function in testicular cancer patients by echocardiography. Systolic (Wall Motion Score Index) and diastolic (E/A-ratio and Tissue Velocity Imaging (TVI)) parameters, and serum levels of N-Terminal pro-Brain Natriuretic Peptide (NT-proBNP) were assessed before the start of chemotherapy and 1 year later. Echocardiography data were compared with an age-matched group of healthy controls. Forty-two patients treated with bleomycin, etoposide and cisplatin were evaluated (median age 27 years, range 18–50). Systolic function and E/A-ratio did not change, whereas the median TVI decreased (12.0 vs 10.0 cms⁻¹; P=0.002). Median levels of NT-proBNP increased (5 vs 18 pmoll⁻¹, P=0.034). Compared with controls, TVI before the start of chemotherapy was not significantly different. In conclusion, we found that at a median of 10 months after cisplatin-based treatment for testicular cancer, TVI decreased significantly, indicating a deterioration of diastolic cardiac function. Serum levels of NT-proBNP increased. The prognostic significance of these changes for future cardiovascular morbidity is not clear.

Early Epirubicin‐Induced Myocardial Dysfunction Revealed by Serial Tissue Doppler Echocardiography: Correlation with Inflammatory and Oxidative Stress Markers

A phase II, open, nonrandomized trial was carried out in a group of epirubicin-treated patients with cancer at different sites with the aim of detecting early preclinical changes that are predictive of the risk for heart failure. All patients underwent conventional echocardiography, as well as tissue Doppler imaging (TDI) with strain (sigma) and strain rate (SR), a very accurate technique for detecting minimal changes in cardiac left ventricular (LV) function. Moreover, echocardiographic changes identified during epirubicin treatment were compared with those of a series of biochemical markers of both myocardial damage and inflammation/oxidative stress. Sixteen patients (male-to-female ratio, 3:13; mean age +/- standard deviation, 56 +/-3 years; range, 27-75 years) with histologically confirmed tumors at different sites, scheduled to be treated with an epirubicin-based chemotherapy regimen, were enrolled in the study. A significant impairment in systolic LV function was observed after 200 mg/m2 of epirubicin; this was shown by a lower SR peak compared with baseline (1.82 +/- 0.57/second versus 1.45 +/- 0.44/second), whereas sigma remained unchanged. The following significant changes in LV diastolic function occurred only after 300 mg/m2 of epirubicin: a decrease in conventional early/late diastolic (E/A) velocities (1.16 +/- 0.31 versus 0.93 +/- 0.24) and a reduction in both the E(m) wave in the basal portion of the interventricular septum (8.86 +/- 1.73 cm/second versus 7.51 +/- 2.30 cm/second) and in the E(m)/A(m) ratio (1.09 +/- 0.51 versus 0.83 +/- 0.51), as measured using the TDI technique. No significant changes in LV ejection fraction were observed. Baseline values of brain natriuretic peptide, troponin I, myoglobin, and creatine kinase-myocardial subfraction were within the normal range and no significant changes were observed throughout the study. Levels of interleukin (IL)-6 and its soluble receptor (sIL-6R) and reactive oxygen species increased significantly, whereas glutathione peroxidase (GPx) levels decreased significantly, after 200 mg/m2 of epirubicin. Significant correlations between the reduction in the SR peak (deltaSR) after 200 mg/m2 of epirubicin and the increase in IL-6 and ROS and decrease in GPx were observed. The multiple regression analysis showed that the only independent predictive variable for deltaSR was ROS level. Our data show that: (a) subtle cardiac abnormalities may occur at epirubicin doses significantly below those known to be potentially clinically harmful and (b) the earliest myocardial impairment affects LV systolic rather than diastolic function. Early contractility impairment during epirubicin treatment was associated with high levels of ROS and markers of inflammation. The clinical meaningfulness of our findings warrants further investigations in a larger number of patients for a longer period of follow-up.

Myocardial Regeneration by Exogenous and Endogenous Progenitor Cells

A problem in need of resolution concerns the origin of cardiac progenitor cells and the mechanisms by which these cells are preserved within the cardiac niches. This may be accomplished by migration of progenitor cells from the bone marrow to the myocardium. Alternatively, the progenitor cell compartment in the heart may be maintained by asymmetric division of resident cells. These two possibilities are not mutually exclusive and both exogenous and endogenous progenitor cells may contribute to cardiac homeostasis.

Solamargine upregulation of Fas, downregulation of HER2, and enhancement of cytotoxicity using epirubicin in NSCLC cells

Nonsmall-cell lung cancer (NSCLC) is not generally a chemosensitive tumor, and the mechanism of resistance to the relevant anticancer drugs has not been fully elucidated. Solamargine (SM), the major steroidal glycoalkaloids extracted from the Chinese herb Solanum, inhibits the growth of human tumor cells. We have previously demonstrated that SM regulates tumor necrosis factor receptors (TNFRs)- and mitochondria-mediated pathways and sensitizes NSCLC cells to initiate apoptosis. Interestingly, this investigation reveals that SM up-regulated Fas expression and down-regulated the expression of HER2, whose overexpression is associated with resistance to drugs, and promotes chemotherapy-induced apoptosis in NSCLC A549 and H441 cells. After treatment with SM, the expression of HER2 mRNA was correlated with the expression of topoisomerase IIalpha (TOP2A) mRNA. The combinatory use of low concentrations of SM with low-toxic topoisomerase II inhibitor epirubicin accelerated apoptotic cell death. Therefore, the downregulation of the HER2 and TOP2A expression by SM with epirubicin may partially explain the SM and epirubicin cytotoxicity synergy effect in NSCLC. Results of this study suggest that SM induces Fas and TNFR-induced NSCLC cell apoptosis and reduces HER2 expression. These findings provide the synergistic therapeutic interaction between SM and epirubicin, suggesting that such combinations may be effectively exploited in future human cancer clinical trials.