Acute chemotherapy-induced cardiovascular changes in patients with testicular cancer

Prevalence and impact of endocrine disorders in advanced metastatic cancer patients undergoing cancer-directed therapy: A prospective observational study

BACKGROUND

Noncommunicable diseases (NCDs) contribute significantly to global morbidity and mortality, with cancer being one of the leading causes. In this prospective observational study, we aimed to investigate the prevalence and impact of endocrine disorders, specifically diabetes and thyroid dysfunction, in patients with advanced metastatic cancer undergoing cancer-directed therapy.

METHODS

Over 15 months, we recruited 100 histologically proven advanced metastatic cancer patients from the Department of Medical Oncology Haematology, All India Institute of Medical Sciences, Rishikesh, and conducted institutional-based prospective observational study. All participants over 18 years of age, treatment-naive, and potential candidates for systemic chemotherapy with an expected clinical survival of at least 6 months were included in the study. Patients with prior therapy, secondary neoplasms, and those unable to complete 3 months of palliative chemotherapy were excluded. Patients were assessed for diabetes and thyroid function at presentation, after 3 and 6 months of cancer-directed standard therapy. These data were analyzed, processed, and presented as results.

RESULTS

The mean age of participants was 50.45 years, with a near-equal distribution of males and females. At baseline, 10% of the study population had preexisting endocrine disorders (2% hypothyroidism, 8% diabetes). By the end of 6 months, the prevalence increased to 18%, with females being more affected. Notably, the prevalence of new-onset endocrine disorders during cancer-directed therapy was only 3% for diabetes and 4% for thyroid dysfunction.

CONCLUSION

Analysis of sociodemographic and cancer-related characteristics showed no significant association with changes in diabetic and thyroid status at 3 and 6 months. However, substance use, particularly smoking, was associated with an increased risk of diabetes development (p < .05). Cancer type and treatment regimen did not show statistically significant correlations with endocrine dysfunction.

IMPLICATIONS

Our study highlights the importance of considering endocrine disorders in advanced metastatic cancer patients undergoing therapy. The prevalence of diabetes and thyroid dysfunction increased during cancer-directed therapy, particularly in females. Careful monitoring and timely intervention are essential to improve the quality of life for these patients. Further research is warranted to explore the long-term effects of cancer-directed therapy on endocrine health and develop tailored management strategies for this vulnerable population.

Change in telomere length and cardiovascular risk factors in testicular cancer survivors

BACKGROUND

Testicular cancer (TC) survivors cured with chemotherapy (CT) are prone to develop cardiovascular diseases, as part of an accelerated aging phenotype. A mechanism contributing to these events can be telomere shortening.

PATIENTS AND METHODS

In a prospective cohort of patients with disseminated TC who received cisplatin-based CT, mean absolute leukocyte telomere length (TL) was measured before and 1 year after start of treatment. Cardiovascular risk factors, including development of the metabolic syndrome and hypogonadism, were assessed before and up to 5 years after CT.

RESULTS

For the whole group (n = 55), TL did not change 1 year after CT (5.7 (2.2-13.4) vs. 5.8 kb (1.6-19.2), P = 0.335). At baseline, patients with a BMI >30 kg/m2 (n = 12) had shorter TL (4.9 (2.2-13.4) vs. 6.3 kb (3.1-12.9), P = 0.045), while no age-dependent differences were measured. Patients with TL shortening after 1 year (n = 7) showed a significant increase in diastolic blood pressure (P = 0.007) and triglycerides (P = 0.003), compared to those with unchanged TL. There was no association between telomere shortening after 1 year or short TL at baseline (n = 7+11) and development of metabolic syndrome (25% vs. 21%; P = 0.777), or hypogonadism (38% vs. 17%; P = 0.120) after 5 years.

CONCLUSIONS

A small subset of TC patients treated with cisplatin-based CT showed telomere shortening 1 year after treatment. This shortening was associated to a rise in diastolic blood pressure and triglycerides, but not to newly developed metabolic syndrome and hypogonadism after 5 years.

Physical exercise in patients with testicular cancer treated with bleomycin, etoposide and cisplatin chemotherapy: pulmonary and vascular endothelial function-an exploratory analysis

PURPOSE

Bleomycin, etoposide, and cisplatin combination chemotherapy (BEP) improves the survival of patients with testicular cancer, but is associated with potentially life-threatening toxicities like pneumonitis and thromboembolic events. This study explored the effects of physical exercise in patients with testicular cancer during or after BEP-chemotherapy on pulmonary and vascular endothelial toxicity.

METHODS

In this post hoc analysis of a multicenter randomized clinical trial (NCT01642680), patients with metastatic testicular cancer scheduled to receive BEP-chemotherapy were randomized to a 24-week exercise intervention, initiated during (group A) or after BEP-chemotherapy (group B). Endpoints were pulmonary function (forced vital capacity (FVC), forced expiratory volume in one second (FEV1), lung transfer-coefficient and transfer factor for carbon monoxide (KCO, DLCO) and markers of vascular endothelial dysfunction (von Willebrand factor (vWF) and factor VIII).

RESULTS

Thirty patients were included. Post-chemotherapy, patients declined less in FVC, FEV1 and DLCO in group A compared to group B. Post-chemotherapy, vWF and factor VIII were significantly lower in group A compared to group B. After completion of exercise, started either during BEP-chemotherapy or thereafter, no between-group differences were found. At 1-year post-intervention, significant between-group differences were found in favour of group A in DLCO and KCO.

CONCLUSIONS

Patients who exercised during BEP-chemotherapy better preserved FVC, FEV1 and DLCO, measured directly post-chemotherapy and 1-year post-intervention (DLCO, KCO). This coincided with less increase in vWF and factor VIII measured directly post-chemotherapy. These data support a beneficial role of a physical exercise intervention during BEP-chemotherapy on pulmonary and vascular damage in patients with testicular cancer.

TRIAL REGISTRY

Optimal Timing of Physical Activity in Cancer Treatment (ACT) Registry URL: https://clinicaltrials.gov/ct2/show/NCT01642680 .

TRIAL REGISTRATION NUMBER

NCT01642680.

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.

Cardiovascular Disease in Testicular Cancer Survivors: Identification of Risk Factors and Impact on Quality of Life

PURPOSE

Testicular cancer (TC) treatment is clearly associated with cardiovascular morbidity and mortality. To enable development of preventive strategies for cardiovascular disease (CVD), we assessed cardiometabolic risk factors and quality of life (QoL) in TC survivors.

METHODS

Incidence of coronary artery disease, myocardial infarction, and heart failure after TC treatment was assessed in a multicenter cohort comprising 4,748 patients treated at the age of 12-50 years between 1976 and 2007. Patients who had developed CVD and a random sample from the cohort (subcohort) received a questionnaire on cardiometabolic risk factors and QoL. A subgroup of responders in the subcohort additionally underwent clinical evaluation of cardiovascular risk factors.

RESULTS

After a median follow-up of 16 years, 272 patients had developed CVD. Compared with orchidectomy only, cisplatin combination chemotherapy was associated with an increased CVD risk (hazard ratio [HR], 1.9; 95% CI, 1.1 to 3.1). Patients who were obese or a smoker at diagnosis (HR, 4.6; 95% CI, 2.0 to 10.0 and HR, 1.7; 95% CI, 1.1 to 2.4, respectively), developed Raynaud's phenomenon (HR, 1.9; 95% CI, 1.1 to 3.6) or dyslipidemia (HR, 2.8; 95% CI, 1.6 to 4.7) or had a positive family history for CVD (HR, 2.9; 95% CI, 1.7 to 4.9) had higher CVD risk. More TC survivors with CVD reported inferior QoL on physical domains than survivors who did not develop CVD. Of 304 TC survivors who underwent clinical evaluation for cardiovascular risk factors (median age at assessment: 51 years), 86% had dyslipidemia, 50% had hypertension, and 35% had metabolic syndrome, irrespective of treatment.

CONCLUSION

Cardiovascular events in TC survivors impair QoL. Many TC survivors have undetected cardiovascular risk factors. We advocate early lifestyle adjustments and lifelong follow-up with low-threshold treatment of cardiovascular risk factors, especially in obese and smoking patients treated with platinum-based chemotherapy.

Cardiovascular Risks in Testicular Cancer: Assessment, Prevention, and Treatment

PURPOSE OF REVIEW

Testicular cancer (TC) is the leading cancer in men between 18 and 39 years of age. Current treatment involves tumor resection followed by surveillance and/or one or more lines of cisplatin-based chemotherapy (CBCT) and/or bone marrow transplant (BMT). Ten years after treatment, CBCT has been associated with significant atherosclerotic cardiovascular disease (CVD) including myocardial infarction (MI), stroke, and heightened rates of hypertension, dyslipidemia, diabetes mellitus, and metabolic syndrome (MetS). Additionally, low testosterone levels and hypogonadism contribute to MetS and may further drive CVD.

RECENT FINDINGS

CVD in TCS has been associated with worse physical functioning accompanied by role limitations, decreased energy, and decreased overall health. Exercise may play a role in ameliorating these effects. Systematic CVD screening practices are needed at TC diagnosis and in survivorship. We encourage a multidisciplinary partnership between primary care physicians, cardiologists, cardio-oncologists, medical oncologists, and survivorship providers to address these needs.

Endothelial dysfunction as a complication of anti-cancer therapy

Recent strides in anti-cancer therapeutics have improved longevity and led to a growing population of cancer survivors, who are increasingly likely to die of other causes. Treatment-induced cardiotoxicity is a complication of several therapeutic agents with acute and long-term consequences for cancer patients. Vascular endothelial dysfunction is a precursor and hallmark of ischemic coronary disease and may play a role in anti-cancer therapy-induced cardiotoxicity. This review summarizes clinical evidence for endothelial dysfunction following anti-cancer therapy and extends the discussion to include the impact of therapeutic agents on conduit arteries and the microcirculation. We highlight the role of innate immune system activation and cross-talk between inflammation and oxidative stress as pathogenic mechanisms underlying anti-cancer therapy-induced vascular toxicity. Understanding the impact of anti-cancer agents on the vascular endothelium will inform therapeutic approaches to prevent or reverse treatment-induced cardiotoxicity and may serve as an important tool to predict, monitor, and prevent adverse cardiovascular outcomes in patients undergoing treatment.

Myocardial Ischemia Related to Common Cancer Therapy-Prevention Insights

Modern antineoplastic therapy improves survival and quality of life in cancer patients, but its indisputable benefits are accompanied by multiple and major side effects, such as cardiovascular ones. Endothelial dysfunction, arterial spasm, intravascular thrombosis, and accelerated atherosclerosis affect the coronary arteries, leading to acute and chronic coronary syndromes that negatively interfere with the oncologic treatment. The cardiac toxicity of antineoplastic agents may be mitigated by using adequate prophylactic measures. In the absence of dedicated guidelines, our work provides the most comprehensive, systematized, structured, and up-to-date analyses of the available literature focusing on measures aiming to protect the coronary arteries from the toxicity of cancer therapy. Our work facilitates the implementation of these measures in daily practice. The ultimate goal is to offer clinicians the necessary data for a personalized therapeutic approach for cancer patients receiving evidence-based oncology treatments with potential cardiovascular toxicity.

Incidence and Determinants of Chemotherapy Associated Thromboembolic Events among Ethiopian Patients Treated for Solid Malignancy: A Retrospective Cross-Sectional Study

Venous thromboembolism is a common problem in patients treated for cancer, although the reported incidence varies widely between studies. This was the first study in its kind in Ethiopia and aimed to assess the incidence and determinants of chemotherapy associated thromboembolic events among patients treated for solid malignancy. An institution-based retrospective cross-sectional study was conducted from 1st March to 1st June, 2019 at adult oncology center of Tikur Anbessa Specialized Hospital. Systematic random sampling technique was employed to recruit 423 study participants. Patients who have received at least a single cycle of any chemotherapy regimen were included in the study. Khorana risk assessment tool was used to predict chemotherapy associated thrombosis. Descriptive statistics were used to summarize the data while multivariable logistic regression was employed to explore associations among variables of interest. The median age of study participants was 43 years, which ranged from 14 to 83 years. Majority of the study participants were treated for breast cancer. Thromboembolic events encountered in 43(10.2%) of patients, from which the commonest one being deep venous thrombosis 36 (85.7%), followed by myocardial infarction 5(11.9%). In multivariable logistic regression, blood transfusion, a primary site of cancer with gastrointestinal malignancy and performance status showed statistically significant association towards the occurrences of thromboembolic events. The incidence of chemotherapy associated thromboembolic events among patients treated for solid malignancy was comparable to other studies. Hence, other prospective randomized trials are needed to see the importance of thrombo-prophylaxis in such high-risk patients.

Far-infrared radiation alleviates cisplatin-induced vascular damage and impaired circulation via activation of HIF-1α

Severe vascular damage and complications are often observed in cancer patients during treatment with chemotherapeutic drugs such as cisplatin. Thus, development of potential options to ameliorate the vascular side effects is urgently needed. In this study, the effects and the underlying mechanisms of far‐infrared radiation (FIR) on cisplatin‐induced vascular injury and endothelial cytotoxicity/dysfunction in mice and human umbilical vein endothelial cells (HUVECs) were investigated. An important finding is that the severe vascular stenosis and poor blood flow seen in cisplatin‐treated mice were greatly mitigated by FIR irradiation (30 minutes/day) for 1‐3 days. Moreover, FIR markedly increased the levels of phosphorylation of PI3K and Akt, and VEGF secretion, as well as the expression and the activity of hypoxia‐inducible factor 1α (HIF‐1α) in cisplatin‐treated HUVECs in a promyelocytic leukemia zinc finger protein (PLZF)‐dependent manner. However, FIR‐stimulated endothelial angiogenesis and VEGF release were significantly diminished by transfection with HIF‐1α siRNA. We also confirmed that HIF‐1α, PI3K, and PLZF contribute to the inhibitory effect of FIR on cisplatin‐induced apoptosis in HUVECs. Notably, FIR did not affect the anticancer activity and the HIF‐1α/VEGF cascade in cisplatin‐treated cancer cells under normoxic or hypoxic condition, indicating that the actions of FIR may specifically target endothelial cells. It is the first study to demonstrate that FIR effectively attenuates cisplatin‐induced vascular damage and impaired angiogenesis through activation of HIF‐1α–dependent processes via regulation of PLZF and PI3K/Akt. Taken together, cotreatment with the noninvasive and easily performed FIR has a therapeutic potential to prevent the pathogenesis of vascular complications in cancer patients during cisplatin treatment.

Single-agent carboplatin AUC10 in metastatic seminoma: A multi-centre UK study of 216 patients

BACKGROUND

Radiotherapy and cisplatin-based combination chemotherapy are accepted standard-of-care treatments for metastatic seminoma with excellent survival outcomes but with established short- and long-term morbidity. Carboplatin monotherapy may be a less toxic alternative; however early historic studies at AUC7 showed inferior outcomes.

OBJECTIVES

To evaluate multi-institutional data on and toxicity and longer-term survival for metastatic seminoma patients treated with the single-agent carboplatin AUC10.

METHODS

We undertook a multi-institutional analysis incorporating all men with the International Germ Cell Cancer Collaborative Group good-prognosis metastatic seminoma treated until 2018. Carboplatin AUC10 was given every 21 days. Toxicity, progression-free survival (PFS), disease-specific survival (DSS) and overall survival were noted. Variables predictive of progression were identified.

RESULTS AND LIMITATIONS

216 patients were treated. The three-year PFS rate was 96.5%, and five-year DSS was 98.3%. There were seven relapses, of which 5 were successfully salvaged with further chemotherapy ± surgery, and three non-seminoma-related deaths. There were no treatment-related deaths. Of 148/216 evaluable patients for toxicity, 37% and 27% suffered >/ = grade III neutropenia and thrombocytopenia, respectively. Twelve percent of patients needed a platelet or blood transfusion (or both). The incidence of febrile neutropenia was 5%.

CONCLUSION

For metastatic seminoma, carboplatin AUC10 harbours a similar oncological efficacy to established therapies, with a low failure risk. The major acute toxicity was myelosuppression. Our study establishes carboplatin AUC10 as another standard-of-care treatment option for good-prognosis metastatic seminoma, with a potentially lower toxicity profile than other therapies.

Risk Factors of Thromboembolism in Lymphoma Patients Undergoing Chemotherapy and its Clinical Significance

This study investigated the risk factors of thromboembolism (TE) in lymphoma patients undergoing chemotherapy and its clinical significance. A total of 304 lymphoma patients who received chemotherapy from January 2012 to July 2019 were retrospectively analyzed, including 111 patients with and 193 patients without TE. The clinical characteristics and related laboratory test results were compared between the 2 groups using univariate analysis, while the risk factors for TE in lymphoma patients undergoing chemotherapy were analyzed using multivariate logistic regression analysis. Univariate analysis revealed an increase in the risk of TE among lymphoma patients with chemotherapy in the following categories: female patients, patients with body mass index <18.5 or > 24, patients aged ≥60 years, those with platelet abnormality before chemotherapy, single hospital-stay patients, and Ann Arbor stage III/IV patients. Multivariate logistic regression analysis revealed that for platelet count abnormality before chemotherapy, Ann Arbor stage III/IV and female patients represented independent risk factors for TE among lymphoma patients after chemotherapy (P < .05). For lymphoma patients treated with chemotherapy, the risk of TE occurring in women, patients with platelet abnormalities before chemotherapy, and patients at Ann Arbor stage III/IV was significantly higher compared with other patients. For these patients, we recommend prophylactic anticoagulant therapy.

Acute inferior myocardial infarction in a young man with testicular seminoma: A case report

BACKGROUND

Atherosclerosis represents the main cause of myocardial infarction (MI); other causes such as coronary embolism, vasospasm, coronary-dissection or drug use are much rarely encountered, but should be considered in less common clinical scenarios. In young individuals without cardiovascular risk factors, the identification of the cause of MI can sometimes be found in the medical history and previous treatments undertaken.

CASE SUMMARY

We present the case of a 34-year-old man presenting acute inferior ST-elevation MI without classic cardiac risk factors. Seven years ago, he suffered from orchidopexy for bilateral cryptorchidism, and was recently diagnosed with right testicular seminoma for which he had to undergo surgical resection and chemotherapy with bleomycin, etoposide and cisplatin. Shortly after the first chemotherapy treatment, namely on day five, he suffered an acute MI. Angiography revealed a mild stenotic lesion at the level of the right coronary artery with suprajacent thrombus and vasospasm, with no other significant lesions on the other coronary arteries. A conservative treatment was decided upon by the cardiac team, including dual antiplatelets therapy and anticoagulants with good further evolution. The patient continued the chemotherapy treatment according to the initial plan without other cardiovascular events.

CONCLUSION

In young individuals with no cardiovascular risk factors undergoing aggressive chemotherapy, an acute MI can be caused by vascular toxicity of several anti-cancer drugs.

Comparison of metabolic changes after neoadjuvant endocrine and chemotherapy in ER-positive, HER2-negative breast cancer

Survival of breast cancer patients has improved, and treatment-related changes regarding metabolic profile deterioration after neoadjuvant systemic treatment (NST) become important issues in cancer survivors. We sought to compare metabolic profile changes and the neutrophil-to-lymphocyte ratio (NLR) between patients undergoing neoadjuvant chemotherapy (NCT) and neoadjuvant endocrine therapy (NET) 3 years after the treatment. In a prospective, randomized, phase III trial which compared 24 weeks of NCT with adriamycin and cyclophosphamide followed by docetaxel and NET with goserelin and tamoxifen (NEST), 123 patients in the Asan Medical Center were retrospectively reviewed to evaluate metabolic changes, such as body mass index (BMI), blood pressure (BP), total cholesterol (TC), fasting glucose, and the NLR. The mean age of patients was 42 years. The changes in BMI, serum glucose, and TC during NST and after 3 years were significantly different between NCT and NET. The proportion of overweight + obese group and the mean BMI were significantly increased during NCT (26.6% to 37.5%, 22.84 kg/m2 to 23.87 kg/m2, p < 0.05), and these attributes found to have normalized at the 3-year follow-up. In the NET group, BMI changes were not observed (p > 0.05, all). There were no differences in changes over time among in the Hypertension group during NCT and NET (p = 0.96). The mean value of serum TC and fasting glucose significantly increased (< 0.05, both) during NCT and decreased 3 years after NCT (p < 0.05); however, no significant changes were observed in the NET group. The NLR was increased from 1.83 to 3.18 after NCT (p < 0.05) and decreased from 1.98 to 1.43 (p < 0.05) after NET. Compared with minimal metabolic effect of NET, NCT worsens metabolic profiles, which were recovered over 3 years. The NLR was increased after NCT but decreased after NET.

Chemotherapy-induced acute vascular injury involves intracellular generation of ROS via activation of the acid sphingomyelinase pathway

Several categories of chemotherapy confer substantial risk for late-term vascular morbidity and mortality. In the present study, we aimed to investigate the mechanism of acute chemotherapy-induced vascular injury in normal tissues. Specifically, we looked at activation of the acid sphingomyelinase (ASMase)/ceramide pathway, which leads to generation of reactive oxygen species (ROS) and induction of oxidative stress that may result in vascular injury. In particular, we focused on two distinct drugs, doxorubicin (DOX) and cisplatin (CIS) and their effects on normal endothelial cells. In vitro, DOX resulted in increased ASMase activity, intra-cellular ROS production and induction of apoptosis. CIS treatment generated significantly reduced effects in endothelial cells. In-vivo, murine femoral arterial blood flow was measured in real-time, during and after DOX or CIS administration, using fluorescence optical imaging system. While DOX caused constriction of small vessels and disintegration of large vessels' wall, CIS induced minor vascular changes in arterial blood flow, correlating with the in vitro findings. These results demonstrate that DOX induces acute vascular injury by increased ROS production, via activation of ASMase/ceramide pathway, while CIS increases ROS production and its immediate extracellular translocation, without causing detectable acute vascular injury. Our findings may potentially lead to the development of new strategies to prevent long-term cardiovascular morbidity in cancer survivors.

The incidence of myocardial infarction and stroke in head and neck cancer patients

Various treatment modalities are used for head and neck cancer (HNC). This study analyzed the incidence and risks of myocardial infarction (MI) and stroke by cancer site and treatment modality in 22,737 patients newly diagnosed with HNC registered in the Korean National Health Insurance Service database in 2007–2013. An additional 68,211 patients without HNC, stroke, or MI were identified as the control group. The risks for MI (hazard ratio [HR] = 1.38, 95% confidence interval [CI] 1.24–1.53), stroke (HR = 1.48, 95% CI 1.37–1.60), and mortality (HR = 5.30, 95% CI 5.14–5.47) were significantly higher in the HNC group. Analysis by cancer site showed the risk of MI and mortality was highest in hypopharynx cancer, while the risk of stroke was highest in nasopharynx and paranasal sinus cancer. Analysis by treatment modality showed the highest risks for MI (HR = 1.88, 95% CI 1.31–2.69) and mortality (HR = 2.95, 95% CI 2.75–3.17) in HNC patients receiving chemotherapy (CT) alone, while HNC patients receiving CT with surgery had the highest risk for stroke (HR = 1.81, 95% CI 1.14–2.88). Careful attention to MI and stroke risks in HNC patients is suggested, especially those who received both CT and radiotherapy.

[Myocardial infarction in a young patient with seminoma during chemotherapy with cisplatinum, etoposide, and bleomycin]

INTRODUCTION

 More than 90 % of all patients with testicular germ cell tumours can be cured effectively. The mainstay of treatment is chemotherapy with cisplatin, etoposide and bleomycin (PEB). This regimen is usually well tolerated and does not lead to serious adverse events. Cardiovascular complications are encountered very rarely, but have gained increasing attention in recent years.

CASE DESCRIPTION

 A 33-year-old man with a testicular seminoma, clinical stage 2b, was subjected to PEB chemotherapy. At the end of the first treatment course, he had an acute ST-elevation myocardial infarction. Coronary angiography revealed a circumscribed stenosis of the left circumflex branch of the left coronary artery with intima dissection and thrombotic deposits. No atherosclerotic changes were found. Management consisted of placement of a drug-eluting coronary stent. Chemotherapy was discontinued and the seminoma treatment completed by radiotherapy with 30 Gy applied to the retroperitoneal mass and a paraaortic template. Complete remission was achieved. 6 months thereafter, the patient was doing well and was disease-free.

COMMENT

 About 0.3 % of all testis cancer patients undergoing cisplatin-based chemotherapy develop cardiovascular complications. Cisplatin-related endothelial damage with secondary thrombotic clotting is assumed to be etiologic in these cases. As there is little comorbidity, the prognostic outlook is favourable in most cases. Caregivers in charge of testis cancer management should be vigilant regarding cardiovascular complications to ensure immediate diagnostic and therapeutic measures in incident cases.

[Using preorchiectomy tumor marker serum concentrations for International Germ Cell Consensus Classification (IGCCCG) risk group assignment results in significant numbers of up- and downstaging]

Hintergrund

Das Klassifikationssystem zur Prognoseeinschätzung der International Germ Cell Cancer Cooperative Group (IGCCCG) für testikuläre Keimzelltumoren basiert auf dem histologischen Subtyp, der Lokalisation des Primärtumors und der Metastasen sowie der Serumkonzentrationen der Tumormarker vor Chemotherapie.

Fragestellung

Ziel der Arbeit war die Evaluation des Einflusses der Verwendung der Tumormarkerserumkonzentrationen vor Ablatio testis im Vergleich zu denen vor Chemotherapie im Hinblick auf die Eingruppierung entsprechend der IGCCCG-Klassifikation.

Material und Methoden

Wir führen eine retrospektive Datenanalyse an 135 Patienten mit metastasiertem testikulärem Keimzelltumor durch, die eine Primärtherapie mit einer Chemotherapie erhalten haben. Es erfolgte die Analyse von klinischen Parametern mit Fokus auf der Tumormarkerserumkonzentration vor Ablatio testis und vor Chemotherapie, die zur Eingruppierung in eine Prognosegruppe entsprechend der IGCCCG-Klassifikation führten.

Ergebnisse

Die Verwendung der Tumormarkerserumkonzentrationen zur Berechnung der IGCCCG-Klassifikation vor der Ablatio testis im Vergleich zu denen vor Chemotherapie führte bei 8 % (11/135) aller Patienten zu einer veränderten Prognosegruppe sowie daraus folgend nicht-leitliniengerechten Therapieschemata. Es zeigt sich ein „up-staging“ bei 8 der 11 Patienten und somit 6 % (8/135) der gesamten Patientenkohorte, d. h. die Serumkonzentrationen der Tumormarker sind nach Ablatio bis zum Beginn der Chemotherapie abgefallen. Bei 3 der 11 Patienten bzw. 2 % (3/135) der gesamten Patientenkohorte, kam es zu einem „down-staging“, d. h. die Tumormarker sind bis zum Beginn der Chemotherapie angestiegen.

Diskussion

Die Verwendung der Tumormarkerserumkonzentrationen vor Ablatio testis im Vergleich zu denen vor Chemotherapie kann zu einer signifikanten IGCCCG-Fehlklassifikation und somit inkorrekter Therapie führen. Für ein leitlinienkonformes „staging“ der Patienten sollten folglich die Tumormarker vor der Chemotherapie verwendet werden.

Thromboembolic Events in Patients with Testicular Germ Cell Tumours Are Predominantly Triggered by Advanced Disease and by Central Venous Access Systems

BACKGROUND

Thromboembolic events (TEEs) may significantly complicate the clinical management of patients with testicular germ cell tumours (GCTs). We analysed a cohort of GCT patients for the occurrence of TEEs and looked to possible pathogenetic factors.

PATIENTS, METHODS

TEEs occurring within 6 months after diagnosis were retrospectively analysed in 317 consecutive patients with testicular GCT (median age 37 years, 198 seminoma, 119 nonseminoma). The following factors were analysed for association with TEE: histology, age, clinical stage (CS), chemotherapy, use of a central venous access device (CVA). Data analysis involved descriptive statistical methods with multivariable analysis to identify independent risk factors.

RESULTS

Twenty-three TEEs (7.3%) were observed, 18 deep vein thromboses, 4 pulmonary embolisms, and 1 myocardial infarction. Univariable risk calculation yielded the following odds ratios (ORs) : >CS1 OR = 43.7 (95% confidence intervals [CIs] 9.9-191.6); chemotherapy OR = 7.8 (95% CI 2.3-26.6); CVA OR = 30.5 (95% CI 11.0-84.3). Multivariable analysis identified only CS > 1 (OR = 16.9; 95% CI 3.5-82.4) and CVA (OR = 9.0; 95% CI 2.9-27.5) as independent risk factors.

CONCLUSIONS

Patients with CSs >CS1 are at significantly increased risk of TEEs even without chemotherapy. Particular high risk is associated with the use of CVA devices for chemotherapy. Caregivers of GCT patients must be aware of the particular risk of TEEs.

Changes in hemodynamics, renal blood flow and urine output during continuous renal replacement therapies

Continuous renal replacement therapies (CRRT) affect hemodynamics and urine output. Some theories suggest a reduced renal blood flow as the cause of the decreased urine output, but the exact mechanisms remain unclear. A prospective experimental study was carried out in 32 piglets (2–3 months old) in order to compare the impact of CRRT on hemodynamics, renal perfusion, urine output and renal function in healthy animals and in those with non-oliguric acute kidney injury (AKI). CRRT was started according to our clinical protocol, with an initial blood flow of 20 ml/min, with 10 ml/min increases every minute until a goal flow of 5 ml/kg/min. Heart rate, blood pressure, central venous pressure, cardiac output, renal blood flow and urine output were registered at baseline and during the first 6 h of CRRT. Blood and urine samples were drawn at baseline and after 2 and 6 h of therapy. Blood pressure, cardiac index and urine output significantly decreased after starting CRRT in all piglets. Renal blood flow, however, steadily increased throughout the study. Cisplatin piglets had lower cardiac index, higher vascular resistance, lower renal blood flow and lower urine output than control piglets. Plasma levels of ADH and urine levels of aquaporin-2 were lower, whereas kidney injury biomarkers were higher in the cisplatin group of piglets. According to our findings, a reduced renal blood flow doesn’t seem to be the cause of the decrease in urine output after starting CRRT.

Robot-assisted retroperitoneal lymphadenectomy: The state of art

Objective

To perform a narrative review about the role of robot-assisted retroperitoneal lymphadenectomy (R-RPLND) in the management of testicular cancer.

Methods

A PubMed search for all relevant publications regarding the R-RPLND series up until August 2019 was performed. The largest series were identified, and weighted means calculated for outcomes using the number of patients included in each study as the weighting factor.

Results

Fifty-six articles of R-RPLND were identified and eight series with more than 10 patients in each were included. The weighted mean age was 31.12 years; primary and post chemotherapy R-RPLND were performed in 50.59% and 49.41% of patients. The clinical stage was I, II and III in 47.20%, 39.57% and 13.23% of patients. A modified R-RPLND template was used in 78.02% of patients, while 21.98% underwent bilateral full template. The weighted mean node yield, operative time and estimated blood loss were, respectively, 22.15 nodes, 277.35 min and 131.94 mL. The weighted mean length of hospital stay was 2 days and antegrade ejaculation was preserved in 92.12% of patients. Major post-operative complications (Clavien III or IV) occurred in 5.34%. Positive pathological nodes were detected in 24.54%, while the recurrence free survival was 95.77% with a follow-up of 21.81 months.

Conclusion

R-RPLND has proven to be a reproducible and safe approach in experienced centers; short-term oncologic outcomes are similar to the open approach with less morbidity and shorter convalescence related to its minimal invasiveness. However, longer follow-up and new trials comparing head-to-head both techniques are expected.

Pathophysiological mechanisms of cardiotoxicity in chemotherapeutic agents

Certain success has been achieved in the treatment of cancer due to the development of various effective chemotherapeutic drugs. However, an increase in their effectiveness (aggressiveness) was associated with a growth of undesirable effects on the entire human body, in particular, on the cardiovascular system. The damage to the cardiovascular system from chemotherapy in many cases is more significant than from the underlying disease. In recent years, a new direction of medicine has been formed - cardio-oncology. The major groups of cardiotoxic chemotherapeutic agents are anthracyclines, inhibitors of epidermal growth factor receptor type 2 (anti-HER2), antimetabolites, microtubule inhibitors, proteasome inhibitors, platinum-based chemotherapeutic drugs, and angiogenesis inhibitors (inhibitors of vascular endothelial growth factor). This review discusses principal pathophysiological mechanisms of the cardiotoxicity of these chemotherapeutic drugs.

Vascular aging in long-term survivors of testicular cancer more than 20 years after treatment with cisplatin-based chemotherapy

BACKGROUND

Late effects of cisplatin-based chemotherapy in testicular cancer survivors (TCS) include cardiovascular morbidity, but little data is available beyond 20 years. The objective was to assess vascular damage in very long-term TCS.

METHODS

TCS (treated with chemotherapy or orchiectomy only) and age-matched healthy controls were invited. Study assessment included vascular stiffness with ultrasound measurement of carotid-femoral pulse wave velocity (cf-PWV).

RESULTS

We included 127 TCS consisting of a chemotherapy group (70 patients) and an orchiectomy group (57 patients) along with 70 controls. Median follow-up was 28 years (range: 20-42). The cf-PWV (m/s) was higher in TCS than in controls (geometrical mean 8.05 (SD 1.23) vs. 7.60 (SD 1.21), p = 0.04). The cf-PWV was higher in the chemotherapy group than in the orchiectomy group (geometrical mean 8.39 (SD 1.22) vs. 7.61 (SD 1.21), p < 0.01). In the chemotherapy group cf-PWV increased more rapidly as a function of age compared to controls (regression coefficient b 7.59 × 10^-3 vs. 4.04 × 10^-3; p = 0.03).

CONCLUSION

Very long-term TCS treated with cisplatin-based chemotherapy show increased vascular damage compatible with "accelerated vascular aging" and continue to be at risk for cardiovascular morbidity, thus supporting the need for intensive cardiovascular risk management.

CLINICAL TRIAL REGISTRATION

The clinical trial registration number is NCT02572934.

Comprehensive Characterization of the Vascular Effects of Cisplatin-Based Chemotherapy in Patients With Testicular Cancer

Background

Cisplatin-based chemotherapy increases the risk of cardiovascular and renal disease.

Objectives

We aimed to define the time course, pathophysiology, and approaches to prevent cardiovascular disease associated with cisplatin-based chemotherapy.

Methods

Two cohorts of patients with a history of testicular cancer (n = 53) were recruited. Cohort 1 consisted of 27 men undergoing treatment with: 1) surveillance; 2) 1 to 2 cycles of bleomycin, etoposide, and cisplatin (BEP) chemotherapy (low-intensity cisplatin); or 3) 3 to 4 cycles of BEP (high-intensity cisplatin). Endothelial function (percentage flow-mediated dilatation) and cardiovascular biomarkers were assessed at 6 visits over 9 months. Cohort 2 consisted of 26 men previously treated 1 to 7 years ago with surveillance or 3 to 4 cycles BEP. Vasomotor and fibrinolytic responses to bradykinin, acetylcholine, and sodium nitroprusside were evaluated using forearm venous occlusion plethysmography.

Results

In cohort 1, the percentage flow-mediated dilatation decreased 24 h after the first cisplatin dose in patients managed with 3 to 4 cycles BEP (10.9 ± 0.9 vs. 16.7 ± 1.6; p < 0.01) but was unchanged from baseline thereafter. Six weeks after starting 3 to 4 cycles BEP, there were increased serum cholesterol levels (7.2 ± 0.5 mmol/l vs. 5.5 ± 0.2 mmol/l; p = 0.01), hemoglobin A1c (41.8 ± 2.0 mmol/l vs. 35.5 ± 1.2 mmol/l; p < 0.001), von Willebrand factor antigen (62.4 ± 5.4 mmol/l vs. 45.2 ± 2.8 mmol/l; p = 0.048) and cystatin C (0.91 ± 0.07 mmol/l vs. 0.65 ± 0.09 mmol/l; p < 0.01). In cohort 2, intra-arterial bradykinin, acetylcholine, and sodium nitroprusside caused dose-dependent vasodilation (p < 0.0001). Vasomotor responses, endogenous fibrinolytic factor release, and cardiovascular biomarkers were not different in patients managed with 3 to 4 cycles of BEP versus surveillance.

Conclusions

Cisplatin-based chemotherapy induces acute and transient endothelial dysfunction, dyslipidemia, hyperglycemia, and nephrotoxicity in the early phases of treatment. Cardiovascular and renal protective strategies should target the early perichemotherapy period. (Clinical Characterisation of the Vascular Effects of Cis-platinum Based Chemotherapy in Patients With Testicular Cancer [VECTOR], NCT03557177; Intermediate and Long Term Vascular Effects of Cisplatin in Patients With Testicular Cancer [INTELLECT], NCT03557164)

Thromboembolic events after high-intensity training during cisplatin-based chemotherapy for testicular cancer: Case reports and review of the literature

The randomized "Testicular cancer and Aerobic and Strength Training trial" (TAST-trial) aimed to evaluate the effect of high-intensity interval training (HIIT) on cardiorespiratory fitness during cisplatin-based chemotherapy (CBCT) for testicular cancer (TC). Here, we report on an unexpected high number of thromboembolic (TE) events among patients randomized to the intervention arm, and on a review of the literature on TE events in TC patients undergoing CBCT. Patients aged 18 to 60 years with a diagnosis of metastatic germ cell TC, planned for 3 to 4 CBCT cycles, were randomized to a 9 to 12 weeks exercise intervention, or to a single lifestyle counseling session. The exercise intervention included two weekly HIIT sessions, each with 2 to 4 intervals of 2 to 4 minutes at 85% to 95% of peak heart rate. The study was prematurely discontinued after inclusion of 19 of the planned 94 patients, with nine patients randomized to the intervention arm and 10 to the control arm. Three patients in the intervention arm developed TE complications; two with pulmonary embolism and one with myocardial infarction. All three patients had clinical stage IIA TC. No TE complications were observed among patients in the control arm. Our observations indicate that high-intensity aerobic training during CBCT might increase the risk of TE events in TC patients, leading to premature closure of the TAST-trial.

Cardiovascular risk and undertreatment of dyslipidemia in lung cancer survivors: A nationwide population-based study

BACKGROUND

In lung cancer survivors, cardiovascular diseases (CVDs) are the leading cause of noncancer deaths. Nonetheless, there is lack of information on management of dyslipidemia, a major risk factor for future CVD events, in lung cancer survivors. This study aimed to assess dyslipidemia management and prevalence of statin eligibility in lung cancer survivors.

METHODS

From the Korean National Health Insurance Service database, we selected 7349 lung cancer survivors who received surgery for lung cancer from 2007 to 2014. We used descriptive statistics for analyses of dyslipidemia management status on the basis of the National Cholesterol Education Program Adult Treatment Panel III guidelines. We also identified those who met the criteria for treatment on the basis of CVD risk according to the 2018 American College of Cardiology and American Heart Association (ACC/AHA) guidelines.

RESULTS

The overall awareness and treatment rates for lung cancer survivors with dyslipidemia were 31.8% and 29.7%, respectively. The overall control rate for those receiving treatment was 88.7%, but was lowest in the highest risk group (78.1%). Furthermore, undertreatment of dyslipidemia was more prominent in young, male lung cancer survivors and those diagnosed with lung cancer within 3 years. Among those not receiving treatment for dyslipidemia, 61.7% were indicated for statin according to the ACC/AHA guidelines.

CONCLUSION

Over half of lung cancer survivors were not receiving treatment, although they were eligible for statin under current guidelines. To reduce noncancer mortality, statin use and adequate management of CVD risk factors should be encouraged in lung cancer survivors.

Arterial hypertension in patients under antineoplastic therapy: a systematic review

BACKGROUND

Cardio-oncology aims to mitigate adverse cardiovascular manifestations in cancer survivors, but treatment-induced hypertension or aggravated hypertension has received less attention in these high cardiovascular risk patients.

METHODS

In this systematic review, we searched literature for contemporary data on the prevalence, pathophysiologic mechanisms, treatment implications and preventive strategies of hypertension in patients under antineoplastic therapy.

RESULTS

Several classes of antineoplastic drugs, including mainly vascular endothelial growth factor inhibitors, proteasome inhibitors, cisplatin derivatives, corticosteroids or radiation therapy were consistently associated with increased odds for new-onset hypertension or labile hypertensive status in previous controlled patients. Moreover, hypertension constitutes a major risk factor for chemotherapy-induced cardiotoxicity, which is the most serious cardiovascular adverse effect of antineoplastic therapy. Despite the heterogeneity of pooled studies, the pro-hypertensive profile of examined drug classes could be attributed to common structural and functional disorders. Importantly, certain antihypertensive drugs are considered to be more effective in the management of hypertension in this population and may partially attenuate indirect complications of cancer treatment, such as progressive development of cardiomyopathy and/or cardiovascular death. Nonpharmacological approaches to alleviate hypertension in cancer patients are also described, albeit adjudicated as less effective in general.

CONCLUSION

A growing body of evidence suggests that multiple antineoplastic agents increase the rate of progression of hypertension. Physicians need to balance the life-saving cancer treatment and the inflated risk of adverse cardiovascular events due to suboptimal management of hypertension in order to achieve improved clinical outcomes and sustained survival for their patients.

The Relationship Between Cisplatin-related and Age-related Hearing Loss During an Extended Follow-up

OBJECTIVES

Cisplatin-related hearing loss (HL) is claimed to progress after treatment. This controlled longitudinal study with extended follow-up investigates HL in testicular cancer survivors (TCSs) after cisplatin-based chemotherapy (CBCT).

STUDY DESIGN

Controlled longitudinal study.

METHODS

Eighty-two TCSs treated with CBCT between 1980 and 1994 in Norway participated in two surveys (S1/S3), including pure-tone audiograms (0.125-8 kHz) and self-reported HL, 12 and 31 years after treatment, respectively. Hearing thresholds were age-adjusted based on age-matched hearing thresholds from the general population (controls). Hearing loss was defined as thresholds >20 dB at any frequency.

RESULTS

Between the two surveys, the prevalence of high-frequency HL (4, 6, and 8 kHz) increased from 73% to 94% but approached those of the aging general population after age adjustment. In TCSs aged >40 years at first survey, HL at the subsequent survey equaled that of controls. Self-reported HL increased from seven (9%) at S1 to 20 (26%) at S3. At S1, age-adjusted HL was identified in all (seven) TCSs reporting decreased hearing whereas at S3, hearing thresholds did not differ from controls in seven out of 20 patients reporting HL.

CONCLUSION

CBCT-related ototoxicity causes high-frequency HL, but in contrast to reports from follow-up studies from the first post-treatment decade, no major progression was found beyond the first post-treatment decade for frequencies 0.125-8 kHz. Importantly, with extended follow-up, hearing thresholds of patients approach those of the general population, possibly due to a less-than-additive effect with age-related hearing loss (ARHL) in CBCT-treated patients. Age-and sex-matching is strongly advised in long-term follow-up of CBCT-related ototoxicity. Specificity for detecting ototoxicity with self-reported questionnaires decreases with extended follow-up.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:E515-E523, 2020.

Cisplatin related cardiotoxicity - acute and chronic cardiovascular morbidity in a testicular cancer survivor

Testicular germ cell tumours are the most common malignancy in men aged 20 to 40 years. They are subdivided into seminoma and non-seminomatous germ cell tumours (NSGCTs). Both seminoma and NSGCT occur at about the same rate, however some tumours contain a combination of both. Cisplatin-based chemotherapy is used adjuvantly in high-risk stage 1 mixed and NSGCT patients and contributes towards oncological cure in almost all metastatic cases, regardless of histology. However, cardiovascular toxicity is a major concern. In addition to acute endothelial toxicity and associated risk of arterial thrombosis, accelerated atherosclerosis may be the result of chemotherapy-associated latent cardio-metabolic dysfunction. A 45-year-old man began treatment with cisplatin-based chemotherapy for testicular cancer. On day 9, he suffered an anterior ST segment elevation myocardial infarction (STEMI). There was proximal occlusion of the left anterior descending (LAD) artery but otherwise normal coronary arteries. Ten months following chemotherapy, he had another STEMI. There was a fresh obstructive lesion in the previously angiographically normal mid LAD, new diffuse coronary atheroma elsewhere and a deterioration in lipid profile despite statin therapy. Acute and longer-term cardiovascular risks of cisplatin-based chemotherapy may have different underlying pathophysiological mechanisms. These issues are of growing relevance in a population of patients expected to have excellent cancer-related outcomes.

Breast cancer drugs perturb fundamental vascular functions of endothelial cells by attenuating protein S-nitrosylation

Cardiovascular side effects of broadly used chemotherapeutic drugs such as Tamoxifen citrate (TC), Capecitabine (CP) and Epirubicin (EP) among cancer survivors are well established. Nitric oxide (NO) is known to protect cardiovascular tissues under conditions of stress. NO can act through cyclic guanosine monophosphate (cGMP)-dependent and -independent pathways. Particularly, the S-nitrosylation of SH-groups in a protein by NO falls under cGMP-independent effects of NO. TC, CP, and EP are hypothesized as interfering with cellular protein S-nitrosylation, which, in turn, may lead to endothelial dysfunctions. The results show that all three drugs attenuate nitrosylated proteins in endothelial cells. A significant reduction in endogenous S-nitrosylated proteins was revealed by Saville-Griess assay, immunofluorescence and western blot. Incubation with the drugs causes a reduction in endothelial migration, vasodilation and tube formation, while the addition of S-nitrosoglutathione (GSNO) has a reversal of this effect. In conclusion, results indicate the possibility of decreased cellular nitrosothiols as being one of the reasons for endothelial dysfunctions under TC, CP and EP treatment. Identification of the down-regulated S-nitrosylated proteins so as to correlate their implications on fundamental vascular functions could be an interesting phenomenon.

Imaging of Metastatic Germ Cell Tumors in Male Patients From Initial Diagnosis to Treatment-Related Toxicities: A Primer for Radiologists

OBJECTIVE. This review describes the influence of histology and metastatic sites on prognosis in male patients with metastatic germ cell tumors (GCTs) and explains the role imaging in assessing therapeutic response, residual disease, recurrence, sand treatment-related toxicities. CONCLUSION. Seminomatous and nonseminomatous GCTs differ in imaging appearance, pattern of spread, and prognosis, and an organ-based approach is helpful in prognostication. Multimodality imaging aids in accurate staging, prognostication, characterization of treatment response, and identification of therapy-related toxicity.

Increased risk of coronary heart disease and stroke in lung cancer survivors: A Korean nationwide study of 20,458 patients

OBJECTIVES

With advances in lung cancer treatments, the number of lung cancer survivors has increased. As cardiovascular diseases (CVD) are some of the major causes of non-cancer deaths, CVD management is an integral part of cancer survivorship care. However, there is sparsity of data on cardiovascular risk in lung cancer survivors who underwent lung cancer surgery. We aimed to compare the incidence of CVD between lung cancer survivors and the general non-cancer population.

MATERIALS AND METHODS

Using the Korean National Health Insurance Service Database, we selected 20,458 patients who underwent surgery for lung cancer between 2007 and 2013. Study outcome variables were coronary heart disease (CHD), myocardial infarction (MI), ischemic stroke (IS), and death. Patients were followed until 2016.

RESULTS

A total of 20,458 lung cancer patients undergoing lung cancer surgery were compared to 27,321 non-cancer control subjects. Lung cancer survivors showed a greater risk for all cardiovascular (CV) events (adjusted hazard ratio [aHR] = 1.27, 95% confidence interval [CI]: 1.19-1.36), CHD (aHR = 1.26, 95% CI: 1.16-1.36), and IS (aHR = 1.22, 95% CI: 1.07-1.39). Chemotherapy and radiotherapy were associated with an increased risk of CV events, CHD, and MI. Lung cancer survivors who were CV event-free for one year, and up to three years, were still at a higher risk for all CV events compared to the non-cancer control population.

CONCLUSIONS

Lung cancer survivors showed an increased risk of CHD and IS compared with the general non-cancer population. Therefore, paying careful attention to cardiovascular risk in lung cancer survivors is suggested, especially for those who receive chemotherapy and/or radiotherapy, in order to ensure both early and long-term survivorship.

Anti-cancer drugs-induced arterial injury: risk stratification, prevention, and treatment

Vascular side effects of standard chemotherapeutic drugs and novel anti-tumor agents complicate treatment cycles, increase non-cancer-related mortality rates, and decrease the quality of life in cancer survivors. Arterial thromboembolic events (ATEE) are associated with most anti-cancer medications. Previous articles have reported a variety of vascular events including ST-segment elevation myocardial infarction as one of the most severe acute arterial attacks. Cardiologists should play an early role in identifying those at high risk for vascular complications and tailor anti-thrombotic therapies in keeping with thromboembolic and bleeding risks. Early preventive steps and individualized chemotherapy may decrease anti-tumor treatment-related vascular events. Here, we aim to provide an extensive review of anti-tumor drug-induced vascular injury (DIVI), pathomechanisms, and risk stratification underlining arterial events. We give a summary of clinical manifestations, treatment options, and possible preventive measures of DIVI. Additionally, the treatment of modifiable risk factors and tailored choice of chemotherapy must be considered in all oncology patients to prevent DIVI. We propose a complex tool for ATEE risk stratification which is warranted for early prediction leading to less frequent complications in cancer patients.

Cortical blindness due to cerebral infarct in advanced pancreatic cancer

A 65-year-old man, a known case of advanced pancreatic cancer on cisplatin and gemcitabine-based chemotherapy, presented with sudden bilateral painless loss of vision with altered sensorium. Clinical examination showed a normal pupillary light reaction, normal anterior segment and normal fundus. MRI brain showed bilateral parieto-occipital infarct. This report highlights the incidence of cortical blindness due to thromboembolism at the cerebral level in pancreatic cancer. Cerebral ischaemic events occur at an advanced stage of pancreatic cancer already diagnosed at stroke onset and portend a poor prognosis. Anticoagulation therapy, especially low molecular weight heparin, remains the best strategy to prevent recurrences.

Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review

The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.

Current controversies on the role of lymphadenectomy for testicular cancer for the journal: Urologic Oncology: Seminars and Original Investigations for the special seminars section on the role of lymphadenectomy for urologic cancers

The role of surgery in the locoregional management of many solid tumors has long been established. For testicular cancer, the incorporation of lymphadenectomy has played an important part in generating long-term survival outcomes in excess of 90% for germ cell tumor patients. In this review, we address several clinical scenarios in which lymphadenectomy at times is underutilized, and others ill advised.

Resting and exercise arterial dysfunction in anthracycline-treated adult survivors of childhood cancers

BACKGROUND

Emerging evidence suggests potential arterial damage with the use of anthracycline-based chemotherapeutic regimens. We determined arterial function at rest and during exercise in anthracycline-treated adult survivors of childhood cancers.

METHODS

Ninety-six adult survivors (54 males) aged 25.0 ± 5.9 years and 60 (30 males) healthy controls were studied. Central systolic blood pressure (cSBP) and radial augmentation index (rAI) was determined by applanation tonometry. Carotid arterial stiffness and intima-media thickness (IMT) were assessed using high-resolution ultrasound.

RESULTS

At rest, survivors had significantly greater carotid IMT (p < 0.001) and stiffness index (p < 0.001), and higher cSBP (p = 0.037), rAI (p = 0.004) and rAI adjusted for a heart rate of 75/min (p = 0.009) than controls. At submaximal supine exercise testing, survivors had significantly greater percentage increase in carotid stiffness than controls (p < 0.001). Among survivors, 32 and 53% had respectively carotid IMT and exercise stiffness index exceeding normal (> + 2SD of controls). The slopes of increase in carotid IMT (p < 0.001) and exercise-induced changes in carotid stiffness (p < 0.001) with age were significantly greater in survivors than controls. Multivariate analysis revealed carotid IMT (β = 0.32, p < 0.001) to be an significant correlate of dynamic percentage increase in stiffness index during exercise.

CONCLUSIONS

Arterial dysfunction is evident at rest and worsens during exercise in anthracycline-treated adult survivors of childhood cancers.

Arterial elasticity as a risk factor for early cardiovascular disease among testicular cancer survivors treated with platinum-based chemotherapy: a cross-sectional pilot study

PURPOSE

Testicular cancer survivors who have received platinum-based chemotherapy are at risk for premature cardiovascular disease. The etiology of this risk is not well understood. This pilot study explores the impact of platinum-based chemotherapy on endothelial function.

METHODS

Testicular cancer survivors <30 years old at the time of diagnosis who received platinum-based chemotherapy between 2002 and 2012, as well as 17 similarly aged male controls, were identified. Consented subjects underwent vascular assessment using the HDI/PulseWave CR-2000 Cardiovascular Profiling System and the Endo-PAT2000 system. Biomarkers and functional test markers were compared among cases, controls, and a group of historical controls using two sided two-sampled t-tests and Wilcoxon rank-sum tests.

RESULTS

Thirteen survivors with a median age of 30.2 years and body mass index of 27.3 were enrolled, along with 17 healthy controls with a median age of 27.1 years and body mass index of 24.8. Median time from chemotherapy was 4.7 (range: 0.8-14) years. There was no statistical difference in reactive hyperemia peripheral arterial tonometry ratio between cases and controls (p = 0.574). There was no statistical difference in small or large artery elasticity between cases and controls (p = 0.086) or between cases and historical controls (p = 0.729). There was also no statistical difference in the blood levels of circulating endothelial cells, von Willebrand factor, and vascular cell adhesion molecules. There was a trend toward increased metabolic syndrome in cases (15%) as compared to recruited controls (6%), though this difference was not statistically significant (p = 0.565).

CONCLUSION

Testicular cancer survivors have no clinically significant difference in endothelial function compared to controls 4 years after the completion of chemotherapy. Further research is needed to explore the secondary modifiable causes that may contribute to the risk of premature cardiovascular disease.

ATF3 and PRAP1 play important roles in cisplatin-induced damages in microvascular endothelial cells

BACKGROUND

The early intervention is a rational approach to reduce the cardiovascular disease mortality in cancer patients. Here, we tried to identify potential biomarkers for the endothelial damage caused by cisplatin, a typical chemotherapy compound, and explore its underlying mechanisms.

METHODS

Microarray dataset GSE62523 were utilized to assess the gene differential expression from human micro-vascular endothelial cells (HMEC-1) treated with cisplatin. Then, the potential key genes were further validated by qRT-PCR and the γH2AX level was evaluated to monitor the DNA damages caused by cisplatin.

RESULT

For the 'acute-exposure' settings that HMEC-1 were treated with 12.9 μM cisplatin for 6, 24 and 48 h, ATF3, LRRTM2, VCAM1 and PAPPA were identified as potential key genes in endothelial damage, while for the 'chronic-exposure' settings that cells were exposed to 0.52 μM cisplatin twice a week, SULF2, ACTA2 and PRAP1 were identified. In addition, further in vitro validation showed that knockdown of ATF3 attenuated the γH2AX level in cells exposed to cisplatin for 6 or 24 h and knockdown of PRAP1 increased the γH2AX level in cells exposed to cisplatin for 2 days. Notably, ATF3 has the ability to regulate the expression of HIST1H1D, FBXO6, APP, MDM2, STAT1 and TRAF1, while PRAP1 regulates YWHAB, MDM2, ISG15, LYN and CUL1 during cisplatin-induced DNA damage repair process.

CONCLUSION

ATF3 and PRAP1 play important roles in cisplatin-induced DNA damage repair process. They may serve as potential early surrogate biomarkers of microvascular endothelial damage for cancer patients receiving chemotherapies.

Thromboembolic events in cancer patients on active treatment with cisplatin-based chemotherapy: another look!

Background

The risk of thromboembolic events is higher among cancer patients, especially in patients undergoing chemotherapy. Cisplatin-based regimens claim to be associated with a very high thromboembolic rate. In this study, we report on our own experience with thrombosis among patients on active cisplatin-based chemotherapy.

Methods

Medical records and hospital databases were searched for all the patients treated with any cisplatin-based regimen for any kind of cancer. Thrombosis was considered cisplatin-related if diagnosed any time after the first dose and up to 4 weeks after the last. The Khorana risk assessment model was performed in all cases.

Results

A total of 1677 patients (65.5% males, median age: 50 years) treated with cisplatin-based regimens were identified. Head and neck (22.9%), lung (22.2%), lymphoma and gastric (11.4% each) were the most common primary tumors. Thromboembolic events were reported in 110 (6.6%); the highest was in patients with gastric cancer (20.9%) and the lowest in patients with head and neck cancers (2.3%) and lymphoma (1.6%). Thrombosis included deep vein thrombosis (DVT) in 69 (62.7%), pulmonary embolism (PE) in 18 (16.9%) and arterial thrombosis in 17 (15.6%). A majority (51.1%) of the patients had stage IV disease and only 16% had stage I or II.In a multivariate analysis, significantly higher rates of thrombosis were associated with gastric as the primary tumor, advanced-stage disease, female sex but not age, and the Khorana risk score or type of cisplatin regimen. While the presence of CVC was significantly associated with the risk of thrombosis (p < 0.0001) in the univariate analysis, and such significance was lost in the multivariate analysis (odds ratio, 1.098; 95%CI, 0.603-1.999, p = 0.7599).

Conclusions

Thromboembolic events in cancer patients on active cisplatin-based chemotherapy were commonly encountered. Gastric cancer, regardless of other clinical variables, was associated with the highest risk.

Toxicities Associated with Cisplatin-Based Chemotherapy and Radiotherapy in Long-Term Testicular Cancer Survivors

Testicular cancer has become the paradigm of adult-onset cancer survivorship, due to the young age at diagnosis and 10-year relative survival of 95%. This clinical review presents the current status of various treatment-related complications experienced by long-term testicular cancer survivors (TCS) free of disease for 5 or more years after primary treatment. Cardiovascular disease and second malignant neoplasms represent the most common potentially life-threatening late effects. Other long-term adverse outcomes include neuro- and ototoxicity, pulmonary complications, nephrotoxicity, hypogonadism, infertility, and avascular necrosis. Future research efforts should focus on delineation of the genetic underpinning of these long-term toxicities to understand their biologic basis and etiopathogenetic pathways, with the goal of developing targeted prevention and intervention strategies to optimize risk-based care and minimize chronic morbidities. In the interim, health care providers should advise TCS to adhere to national guidelines for the management of cardiovascular disease risk factors, as well as to adopt behaviors consistent with a healthy lifestyle, including smoking cessation, a balanced diet, and a moderate to vigorous intensity exercise program. TCS should also follow national guidelines for cancer screening as currently applied to the general population.

Gastric myoelectric activity during cisplatin-induced acute and delayed emesis reveals a temporal impairment of slow waves in ferrets: effects not reversed by the GLP-1 receptor antagonist, exendin (9-39)

Preclinical studies show that the glucagon-like peptide-1 (GLP-1) receptor antagonist, exendin (9-39), can reduce acute emesis induced by cisplatin. In the present study, we investigate the effect of exendin (9-39) (100 nmol/24 h, i.c.v), on cisplatin (5 mg/kg, i.p.)-induced acute and delayed emesis and changes indicative of ‘nausea’ in ferrets. Cisplatin induced 37.2 ± 2.3 and 59.0 ± 7.7 retches + vomits during the 0-24 (acute) and 24-72 h (delayed) periods, respectively. Cisplatin also increased (P<0.05) the dominant frequency of gastric myoelectric activity from 9.4 ± 0.1 to 10.4 ± 0.41 cpm and decreased the dominant power (DP) during acute emesis; there was a reduction in the % power of normogastria and an increase in the % power of tachygastria; food and water intake was reduced. DP decreased further during delayed emesis, where normogastria predominated. Advanced multifractal detrended fluctuation analysis revealed that the slow wave signal shape became more simplistic during delayed emesis. Cisplatin did not affect blood pressure (BP), but transiently increased heart rate, and decreased heart rate variability (HRV) during acute emesis; HRV spectral analysis indicated a shift to ‘sympathetic dominance’. A hyperthermic response was seen during acute emesis, but hypothermia occurred during delayed emesis and there was also a decrease in HR. Exendin (9-39) did not improve feeding and drinking but reduced cisplatin-induced acute emesis by ~59 % (P<0.05) and antagonised the hypothermic response (P<0.05); systolic, diastolic and mean arterial BP increased during the delayed phase. In conclusion, blocking GLP-1 receptors in the brain reduces cisplatin-induced acute but not delayed emesis. Restoring power and structure to slow waves may represent a novel approach to treat the side effects of chemotherapy.

Long-term toxicity of cisplatin in germ-cell tumor survivors

CONTEXT

Testicular germ-cell tumors (GCT) are highly curable. A multidisciplinary approach, including cisplatin-based chemotherapy has resulted in cure in the majority of patients with GCT. Thus, the life expectancy of survivors will extend to many decades post-diagnosis. Late treatment toxicities associated with cisplatin-based chemotherapy may impact their future health.

OBJECTIVE

To systematically evaluate evidence regarding the long-term toxicity of cisplatin in GCT survivors.

EVIDENCE ACQUISITION

We carried out a critical review of PubMed/Medline in February 2017 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Identified reports were reviewed according to the Consolidated Standards of Reporting Trials (CONSORT) criteria. Eighty-three publications were selected for inclusion in this analysis.

EVIDENCE SYNTHESIS

Included reports evaluated long-term toxicities of cisplatin-based chemotherapy in GCT survivors. Studies reporting neuro- and ototoxicity, secondary malignancies, cardiovascular, renal and pulmonary toxicities, hypogonadism and infertility were found. Seven studies (8%) reported genetic underpinnings of long-term toxicities and 3 (4%) and 14 (19%) studies correlated long-term toxicities with circulating platinum levels and cumulative dose of cisplatin, respectively. Significant risks for long-term toxicities associated with cisplatin and platinum-based regimens were reported. The cumulative dose of cisplatin and circulating platinum were reported as risk factors. Several single-nucleotide polymorphisms identified patients susceptible to cisplatin compared with wild-type individuals.

CONCLUSIONS

GCT survivors cured with cisplatin-based chemotherapy are at risk for long-term side-effects. Detection of single-nucleotide polymorphisms could be a valuable tool for predicting long-term toxicities.

PATIENT SUMMARY

Herein, this article summarizes the available evidence of long-term toxicity of cisplatin-based chemotherapy in GCT survivors and provide insights from Indiana University.