1
|
Lammers EMJ, Nijdam A, Zijlstra JM, Janus CPM, de Weijer RJ, Appelman Y, Manintveld OC, Teske AJ, van Leeuwen FE, Aleman BMP. Cardiovascular screening outcomes in the Dutch survivorship care program for Hodgkin lymphoma survivors. J Cancer Surviv 2024:10.1007/s11764-024-01561-y. [PMID: 38649650 DOI: 10.1007/s11764-024-01561-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 03/02/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Hodgkin lymphoma (HL) survivors are at increased risk of cardiovascular disease (CVD) due to former lymphoma treatment. In 2013, cardiovascular screening for 5-year HL survivors according to national guidelines was implemented in Dutch survivorship clinics. We aim to assess the following: (1) adherence to screening guidelines and (2) the yield of (risk factors for) CVD in the screening program. METHODS The study population consisted of 5-year HL survivors who received survivorship care at three University Medical Centers from 2013 to 2016 through 2021. Patient characteristics, cardiovascular screening procedures, and outcomes were collected from the medical records. RESULTS In 186 survivors eligible for cardiovascular screening (mean age 47.8 years, 60.8% female), the following diagnostics were performed: complete blood tests (81.0%, median frequency: yearly instead of advised 5-yearly evaluation), electrocardiogram (93.0%), echocardiography (94.6%). Fifty-five percent of survivors had at least one modifiable cardiovascular risk factor (i.e., current smoking, overweight, new/insufficiently controlled hypertension, dyslipidemia, or diabetes). Screening detected ≥ 1 CVD in 31.1% of survivors. Among survivors with available echocardiography report (n = 106), screening detected new aortic and/or mitral valve dysfunction(s) in 51.0% (with grades 3-4 in 4.9%) and impaired left ventricular ejection fraction in 10.3%. CONCLUSIONS Adherence to the screening guidelines in the Dutch HL survivorship care program was reasonable to good and a substantial number of actionable (risk factors for) CVD were diagnosed. IMPLICATIONS FOR CANCER SURVIVORS Our findings inform HL survivors at high risk of late cardiotoxicity about cardiovascular screening findings and demonstrate appropriate therapeutic actions after diagnosis of (risk factors for) CVD.
Collapse
Affiliation(s)
- Eline M J Lammers
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Annelies Nijdam
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Josée M Zijlstra
- Department of Hematology, Amsterdam UMC Location Vrije Universiteit, Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Roel J de Weijer
- Department of Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | | | - Arco J Teske
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| |
Collapse
|
2
|
Qian C, Srivastava DK, Pan J, Hudson MM, Rai SN. Estimating Transition Intensity Rate on Interval-censored Data Using Semi-parametric with EM Algorithm Approach. COMMUN STAT-THEOR M 2023; 53:6038-6054. [PMID: 39100716 PMCID: PMC11293461 DOI: 10.1080/03610926.2023.2239397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/17/2023] [Indexed: 08/06/2024]
Abstract
Phase IV clinical trials are designed to monitor long-term side effects of medical treatment. For instance, childhood cancer survivors treated with chest radiation and/or anthracycline are often at risk of developing cardiotoxicity during their adulthood. Often the primary focus of a study could be on estimating the cumulative incidence of a particular outcome of interest such as cardiotoxicity. However, it is challenging to evaluate patients continuously and usually, this information is collected through cross-sectional surveys by following patients longitudinally. This leads to interval-censored data since the exact time of the onset of the toxicity is unknown. Rai et al. computed the transition intensity rate using a parametric model and estimated parameters using maximum likelihood approach in an illness-death model. However, such approach may not be suitable if the underlying parametric assumptions do not hold. This manuscript proposes a semi-parametric model, with a logit relationship for the treatment intensities in two groups, to estimate the transition intensity rates within the context of an illness-death model. The estimation of the parameters is done using an EM algorithm with profile likelihood. Results from the simulation studies suggest that the proposed approach is easy to implement and yields comparable results to the parametric model.
Collapse
Affiliation(s)
- Chen Qian
- Biostatistics and Bioinformatics Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky, 40202, USA
- Department of Biostatistics and Bioinformatics, University of Louisville, Louisville, Kentucky, 40202, USA
- AbbVie Inc, North Chicago, Illinois, 60064, USA
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, 38105, USA
| | - Jianmin Pan
- Division of Biostatistics and Bioinformatics, Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, Ohio, 45267, USA
- Cancer Data Science Center, Biostatistics and Informatics Shared Resources, College of Medicine, University of Cincinnati, Cincinnati, Ohio, 45267, USA
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, 38105, USA
| | - Shesh N. Rai
- Division of Biostatistics and Bioinformatics, Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, Ohio, 45267, USA
- Cancer Data Science Center, Biostatistics and Informatics Shared Resources, College of Medicine, University of Cincinnati, Cincinnati, Ohio, 45267, USA
| |
Collapse
|
3
|
Corvest V, Marec-Bérard P, Lervat C, Pacquement H, Toulmonde M, Gentet JC, Laurence V, Cleirec M, Mansuy L, Bompas E, Castex MP, Taque S, Filhon B, Tabone MD, Verité C, Entz-Werle N, Saumet L, Guimard G, Pondrom M, Chevreau C, Flandrin J, Duranteau L, Rousset-Jablonski C, Brugières L, Jimenez M, Le Deley MC, Gaspar N, Fresneau B. Late toxicity comparison of alkylating-based maintenance regimen with cyclophosphamide (VAC) vs ifosfamide (VAI) in Ewing sarcoma survivors treated in the randomized clinical trial Euro-EWING99-R1 in France. Int J Cancer 2023; 152:1659-1667. [PMID: 36250317 PMCID: PMC10092329 DOI: 10.1002/ijc.34326] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/12/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
In Euro-EWING99-R1 randomized trial, cyclophosphamide was shown to be noninferior to ifosfamide in the consolidation of standard-risk Ewing sarcoma (SR-EWS) after a common induction with VIDE (vincristine-ifosfamide-doxorubicin-etoposide). We present the results of the late effects analysis of VAC (vincristine-dactinomycin-cyclophoshamide) vs VAI (vincristine-dactinomycin-ifosfamide) conducted in Euro-EWING99-R1 French cohort. Of 267 French randomized patients, 204 were alive and free-of-relapse at 5-years including 172 with available long-term follow-up data concerning cardiac, renal and/or gonadal functions (sex-ratio M/F = 1.3, median age at diagnosis = 14 years): 84 randomized in VAC (median cumulative doses: cyclophosphamide = 9.7 g/m2 , ifosfamide = 59.4 g/m2 ) and 88 in VAI (ifosfamide = 97.1 g/m2 ). With a median follow-up of 10 years (range = 5-17), five late relapses and five second malignancies were recorded. The 10-year event-free survival among 5-year free-of-relapse survivors was similar between VAC and VAI (93% vs 95%, P = .63). We estimated the 10-year cumulative probabilities of cardiac and kidney toxicities at 4.4% (95% confidence interval [95% CI] = 1.1%-7.6%) and 34.8% (95% CI = 26.8%-42.0%), respectively. Cardiac toxicity cumulative probability was similar in both arms, whereas kidney toxicity was higher in VAI (at 10 years, 43.0% vs 25.7%, P = .02), resulting from significant difference in glomerular toxicity (31.1% vs 13.1%, P < .01). At 10 years, gonadal toxicity was observed in 27% and 28% of pubertal men and women, respectively, without significant difference between VAC and VAI. Kidney and gonadal toxicities represent major issues in Euro-EWING99-R1, with significantly higher risk of kidney toxicities with VAI, without significant gonadal toxicity reduction. These results support the need to limit cumulative doses of both alkylating agents and to use mixed regimen as in VIDE-VAC or VDC/IE (vincristine-doxorubicin-cyclophoshamide/ifosfamide-etoposide).
Collapse
Affiliation(s)
- Victoria Corvest
- Department of Children and Adolescents Oncology, Gustave Roussy, Villejuif, France
| | - Perrine Marec-Bérard
- Department of Oncology for Child and Adolescent, Centre Léon Bérard, Pediatric Oncology and Hematology Institute (IHOPe), Lyon, France
| | - Cyril Lervat
- Centre Oscar Lambret, Unité d'Oncologie Pédiatrique, Lille, France
| | | | - Maud Toulmonde
- Département d'Oncologie Médicale, Institut Bergonié, Unités Sarcomes et Phases Précoces, Bordeaux, France
| | - Jean-Claude Gentet
- Department of Pediatric Hematology, Immunology and Oncology, APHM - La Timone Children's Hospital, Marseille, France
| | - Valérie Laurence
- Medical Oncology, Adolescents and Young Adults Unit, Institut Curie, Paris, France
| | - Morgane Cleirec
- Service d'Oncologie Pédiatrique, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Ludovic Mansuy
- Department of Pediatric Hematology and Oncology, Nancy University Hospital, Vandœuvre-lès-Nancy, France
| | - Emmanuelle Bompas
- Department of Medical Oncology, Centre René Gauducheau, Nantes, France
| | | | - Sophie Taque
- Department of Pediatric Onco-Hematology, Rennes University Hospital, Rennes, France
| | - Bruno Filhon
- Department of Pediatric Hematology and Oncology, Rouen University Hospital, Rouen, France
| | - Marie-Dominique Tabone
- Service d'Hémato-Oncologie Pédiatrique, Hôpital Armand Trousseau - AP-HP, Sorbonne Université, Paris, France
| | - Cécile Verité
- Department of Pediatric and Adolescent Hematology and Oncology, Pellegrin Hospital, Bordeaux, France
| | - Natacha Entz-Werle
- Pédiatrie Onco-Hématologie, Hôpital Universitaire de Strasbourg, Strasbourg, France
| | - Laure Saumet
- Service d'Onco-Hématologie Pédiatrique, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Gregory Guimard
- Department of Paediatric Oncology/Hematology, CHU de Reims, American Hospital, Reims, France
| | - Morgane Pondrom
- Department of Pediatric Hemato-Oncology, Nice University Hospital, Nice, France
| | - Christine Chevreau
- Department of Medical Oncology, Institut Claudius Regaud IUCT-O, Toulouse, France
| | - Jennifer Flandrin
- Service de Gynécologie Adolescente et Jeune Adulte (GYNADO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Lise Duranteau
- Service de Gynécologie Adolescente et Jeune Adulte (GYNADO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Christine Rousset-Jablonski
- Département de Chirurgie, Centre Léon Bérard, INSERM U1290, RESearch in HealthcAre PErformance (RESHAPE), Lyon, France
| | - Laurence Brugières
- Department of Children and Adolescents Oncology, Gustave Roussy, Villejuif, France
| | - Marta Jimenez
- Research and Development Department, Unicancer, Paris, France
| | - Marie-Cécile Le Deley
- Unité de Méthodologie et Biostatistiques, Centre Oscar Lambret, Lille, France.,Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France
| | - Nathalie Gaspar
- Department of Children and Adolescents Oncology, Gustave Roussy, Villejuif, France
| | - Brice Fresneau
- Department of Children and Adolescents Oncology, Gustave Roussy, Villejuif, France.,Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France
| |
Collapse
|
4
|
Ehrhardt MJ, Leerink JM, Mulder RL, Mavinkurve-Groothuis A, Kok W, Nohria A, Nathan PC, Merkx R, de Baat E, Asogwa OA, Skinner R, Wallace H, Lieke Feijen EAM, de Ville de Goyet M, Prasad M, Bárdi E, Pavasovic V, van der Pal H, Fresneau B, Demoor-Goldschmidt C, Hennewig U, Steinberger J, Plummer C, Chen MH, Teske AJ, Haddy N, van Dalen EC, Constine LS, Chow EJ, Levitt G, Hudson MM, Kremer LCM, Armenian SH. Systematic review and updated recommendations for cardiomyopathy surveillance for survivors of childhood, adolescent, and young adult cancer from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2023; 24:e108-e120. [PMID: 37052966 DOI: 10.1016/s1470-2045(23)00012-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/07/2022] [Accepted: 01/10/2023] [Indexed: 02/16/2023]
Abstract
Survivors of childhood, adolescent, and young adult cancer, previously treated with anthracycline chemotherapy (including mitoxantrone) or radiotherapy in which the heart was exposed, are at increased risk of cardiomyopathy. Symptomatic cardiomyopathy is typically preceded by a series of gradually progressive, asymptomatic changes in structure and function of the heart that can be ameliorated with treatment, prompting specialist organisations to endorse guidelines on cardiac surveillance in at-risk survivors of cancer. In 2015, the International Late Effects of Childhood Cancer Guideline Harmonization Group compiled these guidelines into a uniform set of recommendations applicable to a broad spectrum of clinical environments with varying resource availabilities. Since then, additional studies have provided insight into dose thresholds associated with a risk of asymptomatic and symptomatic cardiomyopathy, have characterised risk over time, and have established the cost-effectiveness of different surveillance strategies. This systematic Review and guideline provides updated recommendations based on the evidence published up to September, 2020.
Collapse
|
5
|
Watson C, Gadikota H, Barlev A, Beckerman R. A review of the risks of long-term consequences associated with components of the CHOP chemotherapy regimen. J Drug Assess 2022; 11:1-11. [PMID: 35693477 PMCID: PMC9176678 DOI: 10.1080/21556660.2022.2073101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A common chemotherapy regimen in post-transplant lymphoproliferative disease (PTLD) following solid organ transplants (SOT) is cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). This study reviews the quantitative evidence for long-term consequences associated with components of CHOP identified from the Children's Oncology Group Long-Term Follow-Up Guidelines. Cited references were screened using prespecified criteria (English, systematic review, randomized controlled trial n > 100, observation study n > 100, case series n > 20). Relevant data were extracted and synthesized. Of 61 studies, 66% were retrospective cohort studies, 28% were in the US, and 95% enrolled pediatric patients. No study focused specifically on the CHOP regimen. Long-term consequences for CHOP components observed in >3 studies included cardiac toxicity (n = 14), hormone deficiencies/infertility (n = 14), secondary leukemia (n = 7), osteonecrosis (n = 6), and bladder cancer (n = 4). These effects are significant, impact a high percentage of patients, and occur as early as one year after treatment. Although none of the studies focused specifically on the CHOP regimen, 30%, 23%, and 15% evaluated alkylating agents (e.g. cyclophosphamide), anthracyclines (e.g. doxorubicin), and corticosteroids (e.g. prednisone), respectively. All three product classes had a dose-dependent risk of long-term consequences with up to 13.2-fold, 27-fold, 16-fold, 14.5-fold, and 6.2-fold increase in risk of heart failure, early menopause, secondary leukemia, bladder cancer, and osteonecrosis, respectively. Lymphoma patients had significantly elevated risks of cardiac toxicity (up to 12.2-fold), ovarian failure (up to 3.8-fold), and osteonecrosis (up to 6.7-fold). No studies were found in PTLD or SOT. Safe and effective PTLD treatments that potentially avoid these long-term consequences are urgently needed.
Collapse
Affiliation(s)
- Crystal Watson
- Atara Biotherapeutics Inc., South San Francisco, CA, USA
| | | | - Arie Barlev
- Atara Biotherapeutics Inc., South San Francisco, CA, USA
| | | |
Collapse
|
6
|
Xin N, Chunyan C, You Z, Lu P, Runming J, Fen Z. Case Report: Diffuse Large B Cell Lymphoma After Cardiac Transplantation due to Anthracycline-Induced Dilated Cardiomyopathy in Pediatric Acute Lymphoblastic Leukemia. Front Pharmacol 2022; 13:769751. [PMID: 35517799 PMCID: PMC9065553 DOI: 10.3389/fphar.2022.769751] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/22/2022] [Indexed: 11/17/2022] Open
Abstract
Anthracycline is a first-line chemotherapy drug used to treat childhood acute leukemia, which may cause cardiac toxicity including common arrhythmia, valve disease, pericardial effusion, and even rare cardiomyopathy and cardiac failure. We reported a 2-year-old boy who was treated irregularly for acute lymphoblastic leukemia with daunorubicin. After 26 months, his left ventricular ejection fraction decreased to 40% and progressively decreased to 20–30%. Then he successfully received a heart transplant and the myocardium was confirmed with dilated cardiomyopathy. Eight months after cardiac transplantation, he was admitted again for left neck mass and was diagnosed with monomorphic diffuse large B cell lymphoma associated with Epstein-Barr virus infection by biopsy. We present this case to highlight the importance of standard chemotherapy of daunorubicin, clinical prevention, and monitoring of anthracycline-induced cardiotoxicity in acute lymphoblastic leukemia children to ensure their good prognosis and long-term life quality.
Collapse
Affiliation(s)
- Ning Xin
- Department of Pediatrics, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cao Chunyan
- Department of Ultrasound, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhou You
- Department of Pathology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peng Lu
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin Runming
- Department of Pediatrics, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhou Fen
- Department of Pediatrics, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Zhou Fen,
| |
Collapse
|
7
|
Roundhill EA, Chicon-Bosch M, Jeys L, Parry M, Rankin KS, Droop A, Burchill SA. RNA sequencing and functional studies of patient-derived cells reveal that neurexin-1 and regulators of this pathway are associated with poor outcomes in Ewing sarcoma. Cell Oncol (Dordr) 2021; 44:1065-1085. [PMID: 34403115 PMCID: PMC8516792 DOI: 10.1007/s13402-021-00619-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 12/02/2022] Open
Abstract
PURPOSE The development of biomarkers and molecularly targeted therapies for patients with Ewing sarcoma (ES) in order to minimise morbidity and improve outcome is urgently needed. Here, we set out to isolate and characterise patient-derived ES primary cell cultures and daughter cancer stem-like cells (CSCs) to identify biomarkers of high-risk disease and candidate therapeutic targets. METHODS Thirty-two patient-derived primary cultures were established from treatment-naïve tumours and primary ES-CSCs isolated from these cultures using functional methods. By RNA-sequencing we analysed the transcriptome of ES patient-derived cells (n = 24) and ES-CSCs (n = 11) to identify the most abundant and differentially expressed genes (DEGs). Expression of the top DEG(s) in ES-CSCs compared to ES cells was validated at both RNA and protein levels. The functional and prognostic potential of the most significant gene (neurexin-1) was investigated using knock-down studies and immunohistochemistry of two independent tumour cohorts. RESULTS ES-CSCs were isolated from all primary cell cultures, consistent with the premise that ES is a CSC driven cancer. Transcriptional profiling confirmed that these cells were of mesenchymal origin, revealed novel cell surface targets for therapy that regulate cell-extracellular matrix interactions and identified candidate drivers of progression and relapse. High expression of neurexin-1 and low levels of regulators of its activity, APBA1 and NLGN4X, were associated with poor event-free and overall survival rates. Knock-down of neurexin-1 decreased viable cell numbers and spheroid formation. CONCLUSIONS Genes that regulate extracellular interactions, including neurexin-1, are candidate therapeutic targets in ES. High levels of neurexin-1 at diagnosis are associated with poor outcome and identify patients with localised disease that will relapse. These patients could benefit from more intensive or novel treatment modalities. The prognostic significance of neurexin-1 should be validated independently.
Collapse
MESH Headings
- Adaptor Proteins, Signal Transducing/genetics
- Adaptor Proteins, Signal Transducing/metabolism
- Antineoplastic Agents/pharmacology
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Bone Neoplasms/genetics
- Bone Neoplasms/metabolism
- Calcium-Binding Proteins/genetics
- Calcium-Binding Proteins/metabolism
- Cell Adhesion Molecules, Neuronal/genetics
- Cell Adhesion Molecules, Neuronal/metabolism
- Cell Line, Tumor
- Child
- Doxorubicin/pharmacology
- Gene Expression Regulation, Neoplastic
- Humans
- Kaplan-Meier Estimate
- Neoplastic Stem Cells/drug effects
- Neoplastic Stem Cells/metabolism
- Nerve Tissue Proteins/genetics
- Nerve Tissue Proteins/metabolism
- Neural Cell Adhesion Molecules/genetics
- Neural Cell Adhesion Molecules/metabolism
- Prognosis
- Sarcoma, Ewing/genetics
- Sarcoma, Ewing/metabolism
- Sequence Analysis, RNA/methods
- Transcriptome/genetics
- Tumor Cells, Cultured
- Vincristine/pharmacology
Collapse
Affiliation(s)
- Elizabeth Ann Roundhill
- Children's Cancer Research Group, Leeds Institute of Medical Research, St. James's University Hospital, Leeds, LS9 7TF, UK
| | - Mariona Chicon-Bosch
- Children's Cancer Research Group, Leeds Institute of Medical Research, St. James's University Hospital, Leeds, LS9 7TF, UK
| | - Lee Jeys
- Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| | - Michael Parry
- Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| | - Kenneth S Rankin
- Translational and Clinical Research Institute, Paul O'Gorman Building, Framlington Place, Newcastle upon Tyne, NE2 4AD, UK
| | - Alastair Droop
- Wellcome Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Susan Ann Burchill
- Children's Cancer Research Group, Leeds Institute of Medical Research, St. James's University Hospital, Leeds, LS9 7TF, UK.
| |
Collapse
|
8
|
Asymptomatic systolic dysfunction on contemporary echocardiography in anthracycline-treated long-term childhood cancer survivors: a systematic review. J Cancer Surviv 2021; 16:338-352. [PMID: 33772445 PMCID: PMC8964593 DOI: 10.1007/s11764-021-01028-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022]
Abstract
Purpose Echocardiographic surveillance for asymptomatic left ventricular systolic dysfunction (ALVSD) is advised in childhood cancer survivors (CCS), because of their risk of heart failure after anthracycline treatment. ALVSD can be assessed with different echocardiographic parameters. We systematically reviewed the prevalence and risk factors of late ALVSD, as defined by contemporary and more traditional echocardiographic parameters. Methods We searched databases from 2001 to 2020 for studies on ≥ 100 asymptomatic 5-year CCS treated with anthracyclines, with or without radiotherapy involving the heart region. Outcomes of interest were prevalence of ALVSD—measured with volumetric methods (ejection fraction; LVEF), myocardial strain, or linear methods (fractional shortening; FS)—and its risk factors from multivariable analyses. Results Eleven included studies represented 3840 CCS. All studies had methodological limitations. An LVEF < 50% was observed in three studies in 1–6% of CCS, and reduced global longitudinal strain (GLS) was reported in three studies in 9–30% of CCS, both after a median follow-up of 9 to 23 years. GLS was abnormal in 20–28% of subjects with normal LVEF. Abnormal FS was reported in six studies in 0.3–30% of CCS, defined with various cut-off values (< 25 to < 30%), at a median follow-up of 10 to 18 years. Across echocardiographic parameters, reported risk factors were cumulative anthracycline dose and radiotherapy involving the heart region, with no ‘safe’ dose for ALVSD. Conclusions GLS identifies higher prevalence of ALVSD in anthracycline-treated CCS, than LVEF. Implications for Cancer Survivors The diagnostic and prognostic value of GLS should be evaluated within large cohorts. Protocol registration PROSPERO CRD42019126588 Supplementary Information The online version contains supplementary material available at 10.1007/s11764-021-01028-4.
Collapse
|
9
|
McOwan TN, Craig LA, Tripdayonis A, Karavendzas K, Cheung MM, Porrello ER, Conyers R, Elliott DA. Evaluating anthracycline cardiotoxicity associated single nucleotide polymorphisms in a paediatric cohort with early onset cardiomyopathy. CARDIO-ONCOLOGY 2020; 6:5. [PMID: 32477593 PMCID: PMC7243302 DOI: 10.1186/s40959-020-00060-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 04/29/2020] [Indexed: 12/25/2022]
Abstract
Background Anthracyclines are a mainstay of chemotherapy. However, a relatively frequent adverse outcome of anthracycline treatment is cardiomyopathy. Multiple genetic studies have begun to dissect the complex genetics underlying cardiac sensitivity to the anthracycline drug class. A number of single nucleotide polymorphisms (SNPs) have been identified to be in linkage disequilibrium with anthracycline induced cardiotoxicity in paediatric populations. Methods Here we screened for the presence of SNPs resulting in a missense coding change in a cohort of children with early onset chemotherapy related cardiomyopathy. The SNP identity was evaluated by Sanger sequencing of PCR amplicons from genomic DNA of patients with anthracycline related cardiac dysfunction. Results All of the published SNPs were observed within our patient group. There was no correlation between the number of missense variants an individual carried with severity of disease. Furthermore, the time to cardiac disease onset post-treatment was not greater in those individuals carrying a high load of SNPs resulting from missense variants. Conclusions We conclude that previously identified missense SNPs are present within a paediatric cohort with early onset heart damage induced by anthracyclines. However, these SNPs require further replication cohorts and functional validation before being deployed to assess anthracycline cardiotoxicity risk in the clinic.
Collapse
Affiliation(s)
- Timothy N McOwan
- 1Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052 Australia.,2Department of Pediatrics, The Royal Children's Hospital, University of Melbourne, Parkville, Victoria 3052 Australia
| | - Lauren A Craig
- 1Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052 Australia
| | - Anne Tripdayonis
- 1Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052 Australia
| | - Kathy Karavendzas
- 1Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052 Australia
| | - Michael M Cheung
- 1Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052 Australia.,2Department of Pediatrics, The Royal Children's Hospital, University of Melbourne, Parkville, Victoria 3052 Australia
| | - Enzo R Porrello
- 1Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052 Australia.,3Department of Physiology, School of Biomedical Sciences, The University of Melbourne, Parkville, Victoria 3010 Australia
| | - Rachel Conyers
- 1Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052 Australia.,2Department of Pediatrics, The Royal Children's Hospital, University of Melbourne, Parkville, Victoria 3052 Australia
| | - David A Elliott
- 1Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052 Australia.,2Department of Pediatrics, The Royal Children's Hospital, University of Melbourne, Parkville, Victoria 3052 Australia.,4Australian Regenerative Medicine Institute, Monash University, Clayton, Victoria 3800 Australia
| |
Collapse
|
10
|
Border WL, Sachdeva R, Stratton KL, Armenian SH, Bhat A, Cox DE, Leger KJ, Leisenring WM, Meacham LR, Sadak KT, Sivanandam S, Nathan PC, Chow EJ. Longitudinal Changes in Echocardiographic Parameters of Cardiac Function in Pediatric Cancer Survivors. JACC: CARDIOONCOLOGY 2020; 2:26-37. [PMID: 32719829 PMCID: PMC7384713 DOI: 10.1016/j.jaccao.2020.02.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objectives The purpose of this study was to assess the timing of changes in serial echocardiographic parameters in pediatric cancer survivors and to evaluate their associations with cardiomyopathy development. Background Pediatric cancer survivors undergo serial echocardiograms to screen for cardiotoxicity. It is not clear whether small longitudinal changes in functional or structural parameters over time have clinical significance. Methods This is a multicenter, retrospective, case-control study of ≥1-year survivors following the end of cancer therapy. Cardiomyopathy cases (fractional shortening [FS] ≤28% or ejection fraction [EF] ≤50% on ≥2 occasions) were matched to control subjects (FS ≥30%, EF ≥55%, not on cardiac medications) by cumulative anthracycline and chest radiation dose, follow-up duration, and age at diagnosis. Digitally archived clinical surveillance echocardiograms were quantified in a central core laboratory, blinded to patient characteristics. Using mixed models with interaction terms between time and case status, we estimated the least square mean differences of 2-dimensional, M-mode, pulsed wave Doppler, and tissue Doppler imaging–derived parameters over time between cases and control subjects. Results We identified 50 matched case-control pairs from 5 centers. Analysis of 412 echocardiograms (cases, n = 181; control subjects, n = 231) determined that indices of left ventricular systolic function (FS, biplane EF), diastolic function (mitral E/A ratio), and left ventricular size (end-diastolic dimension z-scores) were significantly different between cases and control subjects, even 4 years prior to the development of cardiomyopathy. Conclusions Longitudinal changes in cardiac functional parameters can occur relatively early in pediatric cancer survivors and are associated with the development of cardiomyopathy.
Collapse
Affiliation(s)
- William L Border
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Sibley Heart Center Atlanta, Georgia
| | - Ritu Sachdeva
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Sibley Heart Center Atlanta, Georgia
| | - Kayla L Stratton
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, California
| | - Aarti Bhat
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - David E Cox
- Children's Healthcare of Atlanta, Sibley Heart Center Atlanta, Georgia
| | - Kasey J Leger
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Wendy M Leisenring
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Lillian R Meacham
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta Aflac Cancer Center, Atlanta, Georgia
| | - Karim T Sadak
- Department of Pediatrics, University of Minnesota, Masonic Children's Hospital, Minneapolis, Minnesota
| | - Shanthi Sivanandam
- Department of Pediatrics, University of Minnesota, Masonic Children's Hospital, Minneapolis, Minnesota
| | - Paul C Nathan
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| |
Collapse
|
11
|
Chen MH. Childhood Cancer Survivors: Screening Little Hearts for Big Problems. JACC CardioOncol 2020; 2:38-40. [PMID: 34396207 PMCID: PMC8352172 DOI: 10.1016/j.jaccao.2020.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Ming Hui Chen
- Departments of Cardiology and Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
| |
Collapse
|
12
|
Feijen EAML, Font-Gonzalez A, Van der Pal HJH, Kok WEM, Geskus RB, Ronckers CM, Bresters D, van Dalen EC, van Dulmen-den Broeder E, van den Berg MH, van der Heiden-van der Loo M, van den Heuvel-Eibrink MM, van Leeuwen FE, Loonen JJ, Neggers SJCMM, Versluys ABB, Tissing WJE, Kremer LCM. Risk and Temporal Changes of Heart Failure Among 5-Year Childhood Cancer Survivors: a DCOG-LATER Study. J Am Heart Assoc 2020; 8:e009122. [PMID: 30595059 PMCID: PMC6405698 DOI: 10.1161/jaha.118.009122] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Heart failure is one of the most important late effects after treatment for cancer in childhood. The goals of this study were to evaluate the risk of heart failure, temporal changes by treatment periods, and the risk factors for heart failure in childhood cancer survivors (CCS). Methods and Results The DCOG‐LATER (Dutch Childhood Oncology Group–Long‐Term Effects After Childhood Cancer) cohort includes 6,165 5‐year CCS diagnosed between 1963 and 2002. Details on prior cancer diagnosis and treatment were collected for this nationwide cohort. Cause‐specific cumulative incidences and risk factors of heart failure were obtained. Cardiac follow‐up was complete for 5,845 CCS (94.8%). After a median follow‐up of 19.8 years and at a median attained age of 27.3 years, 116 survivors developed symptomatic heart failure. The cumulative incidence of developing heart failure 40 years after childhood cancer diagnosis was 4.4% (3.4%–5.5%) among all CCS. The cumulative incidence of heart failure grade ≥3 among survivors treated in the more recent treatment periods was higher compared with survivors treated earlier (Gray test, P=0.05). Mortality due to heart failure decreased in the more recent treatment periods (Gray test, P=0.02). In multivariable analysis, survivors treated with a higher dose of mitoxantrone or cyclophosphamide had a higher risk of heart failure than survivors who were exposed to lower doses. Conclusions CCS treated with mitoxantrone, cyclophosphamide, anthracyclines, or radiotherapy involving the heart are at a high risk for severe, life‐threatening or fatal heart failure at a young age. Although mortality decreased, the incidence of severe or life‐threatening heart failure increased with more recent treatment periods.
Collapse
Affiliation(s)
- E A M Lieke Feijen
- 1 Department of Pediatric Oncology Emma Children's Hospital Amsterdam UMC University of Amsterdam The Netherlands.,2 Prinses Máxima Center for Pediatric Oncology Utrecht The Netherlands
| | - Anna Font-Gonzalez
- 1 Department of Pediatric Oncology Emma Children's Hospital Amsterdam UMC University of Amsterdam The Netherlands
| | | | - Wouter E M Kok
- 3 Department of Cardiology Amsterdam UMC University of Amsterdam The Netherlands
| | - Ronald B Geskus
- 4 Department of Clinical Epidemiology, Biostatistics and Bioinformatics Academic Medical Center Amsterdam the Netherlands.,5 Oxford University Clinical Research Unit Wellcome Trust Major Overseas Programme Ho Chi Minh City Vietnam.,6 Nuffield Department of Medicine University of Oxford United Kingdom
| | - Cécile M Ronckers
- 1 Department of Pediatric Oncology Emma Children's Hospital Amsterdam UMC University of Amsterdam The Netherlands.,2 Prinses Máxima Center for Pediatric Oncology Utrecht The Netherlands
| | - Dorine Bresters
- 2 Prinses Máxima Center for Pediatric Oncology Utrecht The Netherlands
| | - Elvira C van Dalen
- 1 Department of Pediatric Oncology Emma Children's Hospital Amsterdam UMC University of Amsterdam The Netherlands.,2 Prinses Máxima Center for Pediatric Oncology Utrecht The Netherlands
| | | | - Marleen H van den Berg
- 7 Department of Pediatric Oncology/Hematology VU University Medical Center Amsterdam The Netherlands
| | | | - Marry M van den Heuvel-Eibrink
- 2 Prinses Máxima Center for Pediatric Oncology Utrecht The Netherlands.,9 Department of Pediatric Oncology Erasmus MC/Sophia Children's Hospital Rotterdam The Netherlands
| | - Flora E van Leeuwen
- 10 Department of Epidemiology Netherlands Cancer Institute Amsterdam The Netherlands
| | - Jacqueline J Loonen
- 11 Department of Hematology Radboud University Nijmegen Medical Center Nijmegen The Netherlands
| | | | - A B Birgitta Versluys
- 12 Department of Pediatric Oncology University Medical Center Utrecht The Netherlands
| | - Wim J E Tissing
- 2 Prinses Máxima Center for Pediatric Oncology Utrecht The Netherlands.,13 Department of Pediatric Oncology University of Groningen University Medical Center Groningen The Netherlands
| | - Leontien C M Kremer
- 1 Department of Pediatric Oncology Emma Children's Hospital Amsterdam UMC University of Amsterdam The Netherlands.,2 Prinses Máxima Center for Pediatric Oncology Utrecht The Netherlands
| | | |
Collapse
|
13
|
Wolf CM, Reiner B, Kühn A, Hager A, Müller J, Meierhofer C, Oberhoffer R, Ewert P, Schmid I, Weil J. Subclinical Cardiac Dysfunction in Childhood Cancer Survivors on 10-Years Follow-Up Correlates With Cumulative Anthracycline Dose and Is Best Detected by Cardiopulmonary Exercise Testing, Circulating Serum Biomarker, Speckle Tracking Echocardiography, and Tissue Doppler Imaging. Front Pediatr 2020; 8:123. [PMID: 32296665 PMCID: PMC7136405 DOI: 10.3389/fped.2020.00123] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/06/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Survivors of childhood cancer are at risk for anthracycline- and/or radiotherapy-induced cardiotoxicity. Aims: The aim of this study was to assess clinical, laboratory, and imaging parameters of subclinical cardiovascular disease in childhood cancer survivors. Methods: Patients underwent cardiopulmonary exercise test (CPET), laboratory testing, transthoracic echocardiography (TTE) with tissue doppler imaging (TDI) and speckle tracking. A subset of patients also underwent cardiovascular magnetic resonance imaging (CMR). Findings were correlated to cumulative anthracycline and exposure to mediastinal irradiation during cancer treatment. In a subgroup analysis, TTE and CMR findings were compared to data from 40 gender- and age-matched patients with childhood onset hypertrophic cardiomyopathy (HCM). Results: Cardiac evaluation was performed in 79 patients (43 males) at 11.2 ± 4.5 years after cancer treatment. Oncologic diagnosis at a median age of 12.0 years was Hodgkin lymphoma in 20, sarcoma in 17, acute leukemia in 24, relapse leukemia in 10, and others in 8 patients. Cumulative anthracycline dose exceeded 300 mg/m2 in 28 patients. Twenty six patients also received mediastinal irradiation. Decreased peak respiratory oxygen uptake in % predicted on CPET, increased levels of N-terminal pro-brain natriuretic peptide (NTproBNP), increased global longitudinal strain on TTE speckle tracking, and diastolic dysfunction on TDI were the most prominent findings on detailed cardiology follow-up. In contrast to HCM patients, childhood cancer survivors did not show left ventricular hypertrophy (LVPWd z-score median 0.9 vs. 2.8, p < 0.001), hyperdynamic systolic function on TTE (Ejection fraction 62 ± 7 vs. 72 ± 12%, p = 0.001), or fibrotic myocardial changes on CMR (Late gadolinium positive 0/13 vs. 13/36, p = 0.001; extracellular volume fraction 22 ± 2 vs. 28 ± 3, p < 0.001) at time of follow-up. There was no correlation between chest radiation exposure and abnormal cardiac findings. Cumulative anthracycline dose was the only significant independent predictor on multivariate analysis for any cardiovascular abnormality on follow-up (p = 0.036). Conclusion: Increasing cumulative anthracycline dose during cancer treatment correlates with subclinical cardiac dysfunction in childhood cancer survivors best detected by elevated cardiac serum biomarkers, decreased exercise capacity on CPET, and abnormalities on echocardiographic speckle tracking and TDI.
Collapse
Affiliation(s)
- Cordula Maria Wolf
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Barbara Reiner
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Andreas Kühn
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Jan Müller
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Christian Meierhofer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Renate Oberhoffer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Irene Schmid
- Department of Pediatric Hematology and Oncology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jochen Weil
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| |
Collapse
|
14
|
Improving paediatric cardiologists' awareness about the needs of childhood cancer survivors: results of a single-centre directed educational initiative. Cardiol Young 2019; 29:808-812. [PMID: 31280730 DOI: 10.1017/s104795111900088x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cardiovascular disease is a leading cause of morbidity and mortality in childhood cancer survivors. Cardiologists must be aware of risk factors and long-term follow-up guidelines, which have historically been the purview of oncologists. Little is known about paediatric cardiologists' knowledge regarding the cardiotoxicity of cancer treatment and how to improve this knowledge. METHODS A total of 58 paediatric cardiologists anonymously completed a 21-question, web-based survey focused on four cardio-oncology themes: cancer treatment-related risk factors (n = 6), patient-related risk factors (n = 6), recommended surveillance (n = 3), and cardiac-specific considerations (n = 6). Following the baseline survey, a multi-disciplinary team of paediatric cardiologists and cancer survivor providers developed an in-person and web-based educational intervention. A post-intervention survey was conducted 5 months later. RESULTS The response rate was 41/58 (70.7%) pre-intervention and 30/58 (51.7%) post-intervention. On the baseline survey, the percentage of correct answers was 68.8 ± 10.3%, which improved to 79.2 ± 16.2% after the intervention (p = 0.009). The theme with the most profound knowledge deficit was surveillance; however, it also had the greatest improvement after the intervention (49.6 ± 26.7 versus 66.7 ± 27.7% correct, p = 0.025). Individual questions with the largest per cent improvement pertained to risk of cardiac dysfunction with time since treatment (52.4 versus 93.1%, p = 0.002) and the role of dexrazoxane (48.8 versus 82.8%, p = 0.020). CONCLUSION Specific knowledge deficits about the care of paediatric cancer survivors were identified amongst cardiologists using a web-based survey. Knowledge of surveillance was initially lowest but improved the most after an educational intervention. This highlights the need for cardio-oncology-based educational initiatives among paediatric cardiologists.
Collapse
|
15
|
Progressive Elevation of NT-ProBNP During Chemotherapy Is Related to Asymptomatic Cardiovascular Events in Patients With Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 19:167-176.e1. [PMID: 30581158 DOI: 10.1016/j.clml.2018.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/13/2018] [Accepted: 11/02/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients with multiple myeloma (MM) are at risk of cardiovascular events (CVEs) as a result of disease burden- and treatment-related risk factors. Cardiac biomarkers have been reported to be more sensitive than left ventricular ejection fraction in detecting CVEs. We sought to explore CVEs risk factors in MM patients and to establish sensitive predictors of biomarkers. PATIENTS AND METHODS We studied 116 newly diagnosed MM patients who received chemotherapy in our department. Echocardiograms were examined at baseline and after 4 cycles of treatment, as well as upon clinical suspicion of a cardiac event or after an adjustment of treatment regimens. Cardiac biomarkers, including troponin T, myohemoglobin, and N terminal pro B-type natriuretic peptide (NT-proBNP), were estimated before each cycle and within 24 hours after chemotherapy, which was provided for at least 4 cycles. RESULTS Thirteen patients (11.2%) experienced CVEs, seven of which were subclinical. There was no significant difference between the CVE group and the non-CVE group in terms of general patient characteristics, MM disease factors, or chemotherapy drugs. The baseline levels of left ventricular ejection fraction and NT-proBNP were comparable between the 2 groups. NT-proBNP levels increased rapidly after chemotherapy and fell to normal levels before administration of the next cycle in all patients (60 pg/mL vs. 446 pg/mL, P < .001). Patients with asymptomatic CVEs showed a significantly higher proportion of progressively elevated NT-proBNP compared to symptomatic CVE and non-CVE patients (57% vs. 0 vs. 6.1%, P = .035). CONCLUSION The dynamic change in NT-proBNP may predict early asymptomatic cardiac damage and allow interventional strategies to avoid cardiac decompensation.
Collapse
|
16
|
Meiners B, Shenoy C, Zordoky BN. Clinical and preclinical evidence of sex-related differences in anthracycline-induced cardiotoxicity. Biol Sex Differ 2018; 9:38. [PMID: 30157941 PMCID: PMC6114275 DOI: 10.1186/s13293-018-0198-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/16/2018] [Indexed: 01/04/2023] Open
Abstract
Anthracyclines are very effective chemotherapeutic agents that are widely used to treat pediatric and adult cancer patients. Unfortunately, the clinical utility of anthracyclines is limited by cardiotoxicity. There are several established risk factors for anthracycline-induced cardiotoxicity (AIC), including total cumulative dose, very young and very old age, concomitant use of other cardiotoxic agents, and concurrent mediastinal radiation. However, the role of sex as a risk factor for AIC is not well defined. In pediatric cancer patients, most studies support the notion that female sex is a significant risk factor for AIC. Conversely, there is anecdotal evidence that female sex protects against AIC in adult cancer patients. The lack of consistency in study designs and the different definitions of cardiotoxicity preclude reaching consensus regarding the role of sex as a risk factor for AIC in both pediatric and adult cancer patients. Therefore, more clinical research using reliable techniques such as cardiac magnetic resonance imaging is needed to determine if there truly are sex differences in AIC. In adult preclinical rodent studies, however, there is unequivocal evidence that female sex confers significant protection against AIC, with a possible protective effect of female sex hormones and/or a detrimental role of the male sex hormones. Although findings of these rodent studies may not perfectly mirror the clinical scenario in adult anthracycline-treated cancer patients, understanding the mechanisms of this significant sexual dimorphism may reveal important cardioprotective mechanisms that can be therapeutically targeted.
Collapse
Affiliation(s)
- Becky Meiners
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 308 Harvard St S.E, Minneapolis, MN, 55455, USA
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Beshay N Zordoky
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 308 Harvard St S.E, Minneapolis, MN, 55455, USA.
| |
Collapse
|
17
|
Srivastava DK, Zhu L, Hudson MM, Pan J, Rai SN. Robust Estimation and Inference on Current Status Data with Applications to Phase IV Cancer Trial. JOURNAL OF MODERN APPLIED STATISTICAL METHODS 2018. [DOI: 10.22237/jmasm/1530544863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Liang Zhu
- University of Texas Health Science Center at Houston, Houston, TX
| | | | | | | |
Collapse
|
18
|
Armenian SH, Rinderknecht D, Au K, Lindenfeld L, Mills G, Siyahian A, Herrera C, Wilson K, Venkataraman K, Mascarenhas K, Tavallali P, Razavi M, Pahlevan N, Detterich J, Bhatia S, Gharib M. Accuracy of a Novel Handheld Wireless Platform for Detection of Cardiac Dysfunction in Anthracycline-Exposed Survivors of Childhood Cancer. Clin Cancer Res 2018; 24:3119-3125. [DOI: 10.1158/1078-0432.ccr-17-3599] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/15/2018] [Accepted: 03/06/2018] [Indexed: 11/16/2022]
|
19
|
Armstrong GT, Tolle JJ, Piana R, Santucci A, Leathers J, Ness KK, Mulrooney DA, Green DM, Joshi VM, Robison LL, Hudson MM, Lenihan D. Exercise right heart catheterization for pulmonary hypertension identified on screening echocardiography in adult survivors of childhood cancer: A report from the St. Jude Lifetime Cohort. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26769. [PMID: 28843055 PMCID: PMC5699937 DOI: 10.1002/pbc.26769] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/12/2022]
Abstract
Pulmonary hypertension, determined noninvasively by tricuspid regurgitant jet velocity on Doppler echocardiography, was previously identified in 25% of long-term survivors who received chest-directed radiotherapy. To validate noninvasively defined pulmonary hypertension, survivors (mean age 48 years), exposed to chest radiotherapy, underwent right heart catheterization with planned cardiopulmonary exercise testing during catheterization. Eight participants had an elevated mean pulmonary artery pressure at rest (≥25 mm Hg) or with subsequent exercise (>30 mm Hg), evidence of hemodynamically confirmed pulmonary hypertension by right heart catheterization. Cardiopulmonary exercise testing further defined the magnitude and etiology of cardiopulmonary limitations in this life-threatening late effect.
Collapse
Affiliation(s)
- Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital; Memphis Tennessee
- Department of Oncology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - James J. Tolle
- Department of Medicine; Vanderbilt University; Nashville Tennessee
| | - Robert Piana
- Department of Medicine; Vanderbilt University; Nashville Tennessee
| | - Aimee Santucci
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital; Memphis Tennessee
| | - James Leathers
- Department of Medicine; Vanderbilt University; Nashville Tennessee
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital; Memphis Tennessee
| | - Daniel A. Mulrooney
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital; Memphis Tennessee
- Department of Oncology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Daniel M. Green
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital; Memphis Tennessee
| | - Vijaya M. Joshi
- Department of Medicine; The University of Tennessee Health Science Center; Memphis Tennessee
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital; Memphis Tennessee
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital; Memphis Tennessee
- Department of Oncology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Daniel Lenihan
- Department of Medicine; Vanderbilt University; Nashville Tennessee
| |
Collapse
|
20
|
Very Long-term Sequelae After Nonradical Surgery Combined With Brachytherapy in an Infant With a Chemotherapy-resistant Rhabdomyosarcoma of the Tongue. J Pediatr Hematol Oncol 2017; 39:566-569. [PMID: 28859029 DOI: 10.1097/mph.0000000000000935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 2003, van Grotel and colleagues reported an infant suffering a chemotherapy-resistant eRMS of the tongue, that was treated with subtotal tumor resection and brachytherapy after major medical ethical discussions. As no long-term sequelae of such a procedure have been described, perspectives were uncertain at that time. Now, after 15 years, we describe hypoplasia of the mandibula, compromised dentation, osteopenia, neuropsychological deficits, and moderate speech impairment as the most prominent late effects. Also, mandibular cysts and basal cell carcinomas in the irradiated area, eventually led to the diagnosis Gorlin syndrome.
Collapse
|
21
|
Scholz-Kreisel P, Spix C, Blettner M, Eckerle S, Faber J, Wild P, Merzenich H, Hennewig U. Prevalence of cardiovascular late sequelae in long-term survivors of childhood cancer: A systematic review and meta-analysis. Pediatr Blood Cancer 2017; 64. [PMID: 28205419 DOI: 10.1002/pbc.26428] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/01/2016] [Accepted: 12/01/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cardiovascular diseases are well-known late effects of childhood cancer and research on these late effects is a highly important emerging field. We conducted a systematic review with a meta-analysis to give an overview of the current evidence and the prevalence of late cardiovascular events. PROCEDURE We included publications in which the study populations were children and adolescents who survived cancer. Outcome was defined as all cardiovascular clinical and subclinical endpoints or diagnoses appearing at least one year after cancer diagnosis. A systematic overview is presented for all included studies. A quantitative meta-analysis was conducted for hypertension and stroke. RESULTS Sixty-four papers were included in the review. The age range at cancer diagnosis was 0-24 years; age at the end of follow-up ranged from 7 to 71 years. Prevalence of cardiovascular late effects varied from 0% for stroke up to 70% for subclinical hypertension. Large heterogeneity was found regarding study size, study design, definition of endpoints, and investigation/examination method. The weighted average prevalence was 19.7% for hypertension and 2.3% for stroke. As no specific results for gender, cancer therapy, or age at cancer diagnosis were present in most papers, a detailed comparison and pooled analysis was difficult. CONCLUSION This review showed the vast range of cardiovascular late effects after childhood or adolescent cancer therapy. The differences between the papers prevented drawing a conclusive picture of the prevalence of cardiovascular late effects. Large cohort studies and better reporting are needed to improve the knowledge on this topic.
Collapse
Affiliation(s)
- Peter Scholz-Kreisel
- Institute for Medical Biostatistics, Epidemiology and Informatics, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Claudia Spix
- German Childhood Cancer Registry at the Institute for Medical Biostatistics, Epidemiology and Informatics, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Maria Blettner
- Institute for Medical Biostatistics, Epidemiology and Informatics, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Susan Eckerle
- Department of Pediatric Hematology/Oncology, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jörg Faber
- Department of Pediatric Hematology/Oncology, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Philipp Wild
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site RhineMain, Mainz, Germany.,Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Hiltrud Merzenich
- Institute for Medical Biostatistics, Epidemiology and Informatics, University Medicine of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Ulrike Hennewig
- Department of Paediatric Haematology and Oncology, Center for Paediatrics, University Hospital Gießen and Marburg, Giessen, Germany
| |
Collapse
|
22
|
Spewak MB, Williamson RS, Mertens AC, Border WL, Meacham LR, Wasilewski-Masker KJ. Yield of screening echocardiograms during pediatric follow-up in survivors treated with anthracyclines and cardiotoxic radiation. Pediatr Blood Cancer 2017; 64. [PMID: 27966803 DOI: 10.1002/pbc.26367] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Guidelines published by the Children's Oncology Group recommend screening echocardiograms for childhood cancer survivors exposed to anthracyclines and/or cardiotoxic radiation. This study aims to assess risk factors for cardiac late effects while evaluating the overall yield of screening echocardiograms. PROCEDURE Demographics, exposures, and echocardiogram results were abstracted from the medical records of survivors diagnosed at ≤ 21 years old and ≥ 2 years off therapy who were exposed to anthracyclines and/or potentially cardiotoxic radiotherapy. Descriptive statistics and logistic regressions were performed and the yield of screening echocardiograms was calculated. RESULTS Of 853 patients, 1,728 screening echocardiograms were performed, and 37 patients had an abnormal echocardiogram (overall yield 2.1%). Yields were only somewhat higher in more frequently screened patients. Risk factors for an abnormal result included anthracycline dose of ≥300 mg/m2 (adjusted odds ratio [aOR] 3.1; 95% confidence interval [CI]: 1.3-7.2; P < 0.01) with a synergist relationship in patients who also received radiation doses ≥30 Gy (aOR 7.0; 95% CI: 1.6-31.9; P = 0.01), as well as autologous bone marrow transplant (OR 3.3; 95% CI: 1.3-8.5; P = 0.01). Sex, race, age at diagnosis, and cyclophosphamide exposure were not statistically significant risk factors, and no patient receiving <100 mg/m2 anthracycline dose without concomitant radiation had an abnormal echocardiogram. CONCLUSIONS Dose-dependent and synergist anthracycline and cardiotoxic radiotherapy risks for developing cardiomyopathy were confirmed. However, previously identified risk factors including female sex, black race, and early age at diagnosis were not replicated in this cohort. The yields showed weak correlation across frequency categories. Echocardiographic screening recommendations for low-risk pediatric patients may warrant re-evaluation.
Collapse
Affiliation(s)
- Michael B Spewak
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Rebecca S Williamson
- The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ann C Mertens
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - William L Border
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lillian R Meacham
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Karen J Wasilewski-Masker
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| |
Collapse
|
23
|
Hung SH, Rankin A, Virji-Babul N, Pritchard S, Fryer C, Campbell KL. Associating Physical Activity Levels with Motor Performance and Physical Function in Childhood Survivors of Acute Lymphoblastic Leukemia. Physiother Can 2017; 69:57-64. [PMID: 28154445 DOI: 10.3138/ptc.2015-67lhc] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: This cross-sectional, observational study investigated whether physical activity (PA) levels are associated with motor performance and physical function in children after treatment for acute lymphoblastic leukemia (ALL). Method: Participants aged 8-13 years who had completed treatment for ALL (3-36 months post-treatment) were tested at their oncology long-term follow-up appointment at the British Columbia Children's Hospital. PA level was measured using the Physical Activity Questionnaire for Older Children (PAQ-C). Motor performance was measured using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, Short Form (BOT-2 SF), and physical function was measured using the 6-minute walk test (6MWT). Results: Thirteen children completed testing. PAQ-C scores were not associated with BOT-2 SF or 6MWT performance. Eleven children (85%) performed below the norm for the 6MWT. Children with elevated body mass index had poorer 6MWT but similar PAQ-C scores. Conclusion: PA was not found to be associated with motor performance and physical function. Participants who were overweight or obese had poorer 6MWT performance, which may indicate the need for closer monitoring of post-treatment weight status and physical function in the oncology follow-up setting.
Collapse
Affiliation(s)
- Stanley H Hung
- Department of Physical Therapy, University of British Columbia
| | - Anne Rankin
- Department of Physical Therapy, University of British Columbia
| | | | | | | | | |
Collapse
|
24
|
Feijen EAM, Font-Gonzalez A, van Dalen EC, van der Pal HJH, Reulen RC, Winter DL, Kuehni CE, Haupt R, Alessi D, Byrne J, Bardi E, Jakab Z, Grabow D, Garwicz S, Jankovic M, Levitt GA, Skinner R, Zadravec Zaletel L, Hjorth L, Tissing WJE, de Vathaire F, Hawkins MM, Kremer LCM. Late Cardiac Events after Childhood Cancer: Methodological Aspects of the Pan-European Study PanCareSurFup. PLoS One 2016; 11:e0162778. [PMID: 27643694 PMCID: PMC5028033 DOI: 10.1371/journal.pone.0162778] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 08/29/2016] [Indexed: 01/24/2023] Open
Abstract
Background and Aim Childhood cancer survivors are at high risk of long-term adverse effects of cancer and its treatment, including cardiac events. The pan-European PanCareSurFup study determined the incidence and risk factors for cardiac events among childhood cancer survivors. The aim of this article is to describe the methodology of the cardiac cohort and nested case-control study within PanCareSurFup. Methods Eight data providers in Europe participating in PanCareSurFup identified and validated symptomatic cardiac events in their cohorts of childhood cancer survivors. Data on symptomatic heart failure, ischemia, pericarditis, valvular disease and arrhythmia were collected and graded according to the Criteria for Adverse Events. Detailed treatment data, data on potential confounders, lifestyle related risk factors and general health problems were collected. Results The PanCareSurFup cardiac cohort consisted of 59,915 5-year childhood cancer survivors with malignancies diagnosed between 1940 and 2009 and classified according to the International Classification of Childhood Cancer 3. Different strategies were used to identify cardiac events such as record linkage to population/ hospital or regional based databases, and patient- and general practitioner-based questionnaires. Conclusion The cardiac study of the European collaborative research project PanCareSurFup will provide the largest cohort of 5-year childhood cancer survivors with systematically ascertained and validated data on symptomatic cardiac events. The result of this study can provide information to minimize the burden of cardiac events in childhood cancer survivors by tailoring the follow-up of childhood cancer survivors at high risk of cardiac adverse events, transferring this knowledge into evidence-based clinical practice guidelines and providing a platform for future research studies in childhood cancer patients.
Collapse
Affiliation(s)
- Elizabeth A. M. Feijen
- Department of Pediatric Oncology, Emma Children’s Hospital/ Academic Medical Center Amsterdam, meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- * E-mail:
| | - Anna Font-Gonzalez
- Department of Pediatric Oncology, Emma Children’s Hospital/ Academic Medical Center Amsterdam, meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Elvira C. van Dalen
- Department of Pediatric Oncology, Emma Children’s Hospital/ Academic Medical Center Amsterdam, meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Helena J. H. van der Pal
- Department of Pediatric Oncology, Emma Children’s Hospital/ Academic Medical Center Amsterdam, meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- Department of Medical Oncology, Academic Medical Center Amsterdam, meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Raoul C. Reulen
- Department of Medical Oncology, Academic Medical Center Amsterdam, meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - David L. Winter
- Department of Medical Oncology, Academic Medical Center Amsterdam, meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Claudia E. Kuehni
- Swiss Childhood Cancer Registry, Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland
| | - Riccardo Haupt
- Epidemiology and Biostatistics Section, Gaslini Children Hospital, Via Gerolamo Gaslini, 5, 16148, Genova, Italy
| | - Daniela Alessi
- Childhood Cancer Registry of Piedmont, Cancer Epidemiology Unit, Citta' della Salute e della Scienza Hospital-University of Turin and Center for Cancer Prevention (CPO), Via Santena 7, 10126, Torino, Italy
| | - Julianne Byrne
- Boyne Research Institute, Tiernan House, Fair Green, Drogheda, Ireland
| | - Edit Bardi
- 2nd Department of Pediatrics, Semmelweis University, Üllői út 26, 1085, Budapest, Hungary
| | - Zsuzsanna Jakab
- Department of Pediatric Oncology, Markusovszky Hospital, Markusovszky Lajos u. 5, 9700, Szombathely, Hungary
| | - Desiree Grabow
- German Childhood Cancer Registry (GCCR), Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Mainz, Germany
| | - Stanislaw Garwicz
- Department of Pediatrics, Skåne University Lund, Getingevägen 4, 222 41, Lund, Sweden
| | - Momcilo Jankovic
- Pediatric Hematology Unit, San Gerardo Hospital, Via Primo Maggio, 22, 38089, Monza, Italy
| | - Gill A. Levitt
- Department of Paediatric and Adolescent Haematology and Oncology, and Children's BMT Unit, Great North Children's Hospital, Newcastle, United Kingdom
| | - Roderick Skinner
- Department of Paediatric and Adolescent Haematology and Oncology, and Children's BMT Unit, Great North Children's Hospital, and Northern Institute of Cancer Research, Newcastle University, Newcastle, United Kingdom
| | - Lorna Zadravec Zaletel
- Division of Radiotherapy, Institute of Oncology, Zaloška cesta 2 SI– 1000, Ljubljana, Slovenia
| | - Lars Hjorth
- Department of Pediatrics, Skåne University Lund, Getingevägen 4, 222 41, Lund, Sweden
| | - Wim J. E. Tissing
- Department of Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Florent de Vathaire
- Radiation Epidemiology Group, Gustave Roussy, Inserm, UMR1018, Villejuif, France
| | - Mike M. Hawkins
- Department of Public Health, Epidemiology and Biostatistics, Centre for Childhood Cancer Survivor Studies, School of Health and Population Sciences, Public Health Building, University of Birmingham, Birmingham, B15 2TT, United Kingdom
| | - Leontien C. M. Kremer
- Department of Pediatric Oncology, Emma Children’s Hospital/ Academic Medical Center Amsterdam, meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | | |
Collapse
|
25
|
Järvelä LS, Saraste M, Niinikoski H, Hannukainen JC, Heinonen OJ, Lähteenmäki PM, Arola M, Kemppainen J. Home-Based Exercise Training Improves Left Ventricle Diastolic Function in Survivors of Childhood ALL: A Tissue Doppler and Velocity Vector Imaging Study. Pediatr Blood Cancer 2016; 63:1629-35. [PMID: 27198652 DOI: 10.1002/pbc.26051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 04/13/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Advanced echocardiographic methods may reveal signs of late anthracycline cardiac toxicity (ACT) even in asymptomatic patients. We studied echocardiographic tissue Doppler imaging (TDI) and velocity vector imaging (VVI) in long-term survivors of childhood acute lymphoblastic leukemia (ALL) before and after an exercise intervention. METHODS Twenty-one asymptomatic, anthracycline-treated, long-term childhood ALL survivors with matched controls were studied at baseline. Seventeen of the survivors participated in a 3-month home-based exercise program. Echocardiography with TDI and VVI was performed. RESULTS At baseline, ejection fraction (60.7 ± 4.7% vs. 62.3 ± 3.7%, P = 0.22) and fractional shortening (32.6 ± 3.1% vs. 34.0 ± 2.8%, P = 0.13) were similar in survivors and controls. Lateral early diastolic mitral annulus velocity E' (32.81 ± 5.71 cm/sec vs. 38.03 ± 6.21 cm/sec, P = 0.01), E'/A' (1.60 ± 0.48 vs. 2.07 ± 0.63, P = 0.01), and E/E' (2.78 ± 0.35 vs. 2.42 ± 0.62, P = 0.04) were impaired compared to controls. Peak circumferential strain and strain rate were attenuated at apex (-24.50 ± 3.46% vs. -28.06 ± 4.39%, P = 0.01 and -1.47 ± 0.22 sec(-1) vs. -1.68 ± 0.33 sec(-1) , P = 0.02) compared to controls. After the intervention, early diastolic mitral inflow velocity E (87.76 ± 12.54 cm/s vs. 95.28 ± 10.48 cm/s, P = 0.04) and E' increased (31.78 ± 5.50 cm/s vs. 34.96 ± 5.41 cm/s, P < 0.01). Peak circumferential systolic and diastolic strain rates at mid-level (-1.22 ± 0.21 sec(-1) vs. -1.35 ± 0.24 sec(-1) , P = 0.04 and 1.25 ± 0.25 sec(-1) vs. 1.48 ± 0.35 sec(-1) , P < 0.01) improved after the exercise program. CONCLUSIONS A simple home-based exercise program improved cardiac function in asymptomatic childhood ALL survivors. Adding TDI in routine echocardiographic examination may improve the recognition of early signs of ACT, and VVI may bring additional information. The improvements in cardiac function after the exercise program emphasize the importance of physical activity in this population.
Collapse
Affiliation(s)
- Liisa S Järvelä
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Markku Saraste
- Department of Clinical Physiology and Nuclear Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Harri Niinikoski
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland.,Institute of Biomedicine, University of Turku, Turku, Finland
| | | | - Olli J Heinonen
- Paavo Nurmi Centre, Department of Health and Physical activity, University of Turku, Turku, Finland
| | - Päivi M Lähteenmäki
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Mikko Arola
- Department of Paediatrics, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Jukka Kemppainen
- Department of Clinical Physiology and Nuclear Medicine, University of Turku and Turku University Hospital, Turku, Finland.,Turku PET Centre, University of Turku, Turku, Finland
| |
Collapse
|
26
|
Ramjaun A, AlDuhaiby E, Ahmed S, Wang L, Yu E, Nathan PC, Hodgson DC. Echocardiographic Detection of Cardiac Dysfunction in Childhood Cancer Survivors: How Long Is Screening Required? Pediatr Blood Cancer 2015; 62:2197-203. [PMID: 26146944 PMCID: PMC4670474 DOI: 10.1002/pbc.25651] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 06/09/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Childhood cancer survivors treated with anthracycline chemotherapy are at an increased risk of long-term cardiac toxicity, and guidelines recommend that exposed survivors undergo echocardiography every 1-5 years. However, it is unclear whether survivors should undergo echocardiographic screening indefinitely, or if a period of echocardiographic stability indicates that screening is no longer necessary. The objective of this study was to evaluate the outcomes of echocardiographic screening to aid in the refinement of existing guidelines. METHODS We retrospectively analyzed the results of echocardiographic screening in a cohort of adult survivors of childhood cancer treated with anthracyclines and/or cardiac radiation therapy. Interval regression analysis was performed to identify predictors of single-episode or sustained abnormal echocardiograms. RESULTS The cohort constituted 333 survivors, with median follow-up time of 15.8 years post-treatment (range: 5.0-47.9), and median age at treatment of 8 years (range: 1.5-18). Forty-nine survivors had an abnormal echocardiogram (14.7%), and 29 (8.7%) had reproducible abnormal findings. An ongoing continual increase in the incidence of sustained echocardiographic abnormality was seen among patients treated with >250 mg/m(2) doxorubicin at age <5 years, reaching 43% by 20 years of therapy. In contrast, no sustained abnormal echocardiographic findings arose after 10 years of therapy in survivors treated with <250 mg/m(2) at age ≥5 years. CONCLUSIONS Single-episode echocardiographic abnormalities are often not reproduced in subsequent evaluations. The duration of echocardiographic screening for childhood cancer survivors should be reassessed for patients who received lower doses of anthracycline after age 5.
Collapse
Affiliation(s)
- Aliya Ramjaun
- Radiation Medicine Program, Princess Margaret Cancer CentreToronto, Ontario, Canada
| | - Eman AlDuhaiby
- Princess Noorah Oncology CenterKing Abdulaziz Medical City, Saudi Arabia
| | - Sameera Ahmed
- Radiation Medicine Program, Princess Margaret Cancer CentreToronto, Ontario, Canada
| | - Lisa Wang
- Department of Biostatistics, Princess Margaret Cancer CentreToronto, Ontario, Canada
| | - Eric Yu
- Division of Adult Cardiology, Toronto Western HospitalToronto, Ontario, Canada
| | - Paul C Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children and University of TorontoToronto, Ontario, Canada
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer CentreToronto, Ontario, Canada,Division of Hematology/Oncology, The Hospital for Sick Children and University of TorontoToronto, Ontario, Canada,Department of Radiation Oncology, University of TorontoToronto, Ontario, Canada,*Correspondence to: David Hodgson, Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON M5E 2M9., E-mail:
| |
Collapse
|
27
|
Green DM. Doxorubicin in stage II-III, intermediate-risk Wilms' tumour. Lancet 2015; 386:1118-9. [PMID: 26164099 DOI: 10.1016/s0140-6736(15)60686-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Daniel M Green
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN 38105, USA.
| |
Collapse
|
28
|
Vulsteke C, Pfeil AM, Maggen C, Schwenkglenks M, Pettengell R, Szucs TD, Lambrechts D, Dieudonné AS, Hatse S, Neven P, Paridaens R, Wildiers H. Clinical and genetic risk factors for epirubicin-induced cardiac toxicity in early breast cancer patients. Breast Cancer Res Treat 2015; 152:67-76. [PMID: 26017071 DOI: 10.1007/s10549-015-3437-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 12/31/2022]
Abstract
Anthracycline-induced cardiotoxicity (ACT) is a well-known serious adverse drug reaction leading to substantial morbidity. The purpose of this study was to assess ACT occurrence and clinical and genetic risk factors in early breast cancer patients. In 6 genes of interest (ABCC1, ABCC2, CYBA, NCF4, RAC2, SLC28A3), 10 single nucleotide polymorphisms (SNPs) involved in ACT were selected based on a literature search. Eight hundred and seventy-seven patients treated between 2000 and 2010 with 3-6 cycles of (neo) adjuvant 5-fluorouracil, epirubicin and cyclophosphamide (FEC) were genotyped for these SNPs using Sequenom MassARRAY. Main outcome measures were asymptomatic decrease of left ventricular ejection fraction (LVEF) > 10 % and cardiac failure grade 3-5 (CTCAE 4.0). To evaluate the impact of these 10 SNPs as well as clinical factors (age, relative dose intensity of epirubicin, left-sided radiotherapy, occurrence of febrile neutropenia, and planned and received cycles of epirubicin) on decrease of LVEF and cardiac failure, we performed uni- and multivariable logistic regression analysis. Additionally, exploratory analyses including 11 additional SNPs related to the metabolism of anthracyclines were performed. After a median follow-up of 3.62 years (range 0.40-9.60), a LVEF decline of > 10 % occurred in 153 patients (17.5 %) and cardiac failure in 16 patients (1.8 %). In multivariable analysis, six cycles of FEC compared to three cycles received and heterozygous carriers of the rs246221 T-allele in ABCC1 relative to homozygous carriers of the T-allele were significantly associated with LVEF decline of > 10 % (OR 1.3, 95 % CI 1.1-1.4, p < 0.001 and OR 1.6, 95 % CI 1.1-2.3, p = 0.02). Radiotherapy for left-sided breast cancer was associated with cardiac failure (OR 3.7, 95 % CI 1.2-11.5, p 0.026). The other 9 SNPs and clinical factors tested were not significantly associated. In our exploratory analysis, no other SNPs related to anthracycline metabolism were retained in the multivariate model for prediction of LVEF decline. ACT in breast cancer patients is related to number of received cycles of epirubicin and left-sided radiotherapy. Additional studies should be performed to independently confirm the potential association between rs246221 in ABCC1 and LVEF.
Collapse
Affiliation(s)
- Christof Vulsteke
- Integrated Cancer Center Ghent, AZ Maria Middelares, Ghent, Belgium.
| | - Alena M Pfeil
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Charlotte Maggen
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Louvain, Belgium
| | | | - Ruth Pettengell
- Cellular and Molecular Medicine, St. George's University of London, London, United Kingdom
| | - Thomas D Szucs
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Diether Lambrechts
- Vesalius Research Center, Vlaams Instituut voor Biotechnologie (VIB), Louvain, Belgium.,Laboratory for Translational Genetics, Department of Oncology, KU Leuven, Louvain, Belgium
| | - Anne-Sophie Dieudonné
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Louvain, Belgium
| | - Sigrid Hatse
- Laboratory of Experimental Oncology (LEO), Department of Oncology, KU Leuven and Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, Herestraat 49, 3000, Louvain, Belgium
| | - Patrick Neven
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Louvain, Belgium
| | - Robert Paridaens
- Laboratory of Experimental Oncology (LEO), Department of Oncology, KU Leuven and Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, Herestraat 49, 3000, Louvain, Belgium
| | - Hans Wildiers
- Laboratory of Experimental Oncology (LEO), Department of Oncology, KU Leuven and Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, Herestraat 49, 3000, Louvain, Belgium
| |
Collapse
|
29
|
Armenian SH, Kremer LC, Sklar C. Approaches to reduce the long-term burden of treatment-related complications in survivors of childhood cancer. Am Soc Clin Oncol Educ Book 2015:196-204. [PMID: 25993157 DOI: 10.14694/edbook_am.2015.35.196] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Advances in diagnostics, treatment strategies, and supportive care have contributed to a marked improvement in outcomes for children with cancer. This has resulted in a growing number of long-term childhood cancer survivors. Currently there are over 360,000 individuals who are survivors of childhood cancer in the United States. However, treatment for patients with childhood cancer with chemotherapy, radiation, and/or hematopoietic stem cell transplantation can result in health-related complications that may not become evident until years after completion of treatment. As a result, several initiatives have been established to help standardize the surveillance for treatment-related late effects in childhood cancer survivors. This review highlights emerging concepts related to commonly reported late effects, such as subsequent malignant neoplasms, cardiovascular disease, and endocrinopathies. It also discusses relevant population-based screening strategies to mitigate the long-term health-related burden in vulnerable populations of survivors.
Collapse
Affiliation(s)
- Saro H Armenian
- From the Department of Population Sciences, City of Hope, Duarte, CA; Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, Netherlands; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leontien C Kremer
- From the Department of Population Sciences, City of Hope, Duarte, CA; Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, Netherlands; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Charles Sklar
- From the Department of Population Sciences, City of Hope, Duarte, CA; Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, Netherlands; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
30
|
Armenian SH, Hudson MM, Mulder RL, Chen MH, Constine LS, Dwyer M, Nathan PC, Tissing WJE, Shankar S, Sieswerda E, Skinner R, Steinberger J, van Dalen EC, van der Pal H, Wallace WH, Levitt G, Kremer LCM. Recommendations for cardiomyopathy surveillance for survivors of childhood cancer: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2015; 16:e123-36. [PMID: 25752563 PMCID: PMC4485458 DOI: 10.1016/s1470-2045(14)70409-7] [Citation(s) in RCA: 375] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Survivors of childhood cancer treated with anthracycline chemotherapy or chest radiation are at an increased risk of developing congestive heart failure. In this population, congestive heart failure is well recognised as a progressive disorder, with a variable period of asymptomatic cardiomyopathy that precedes signs and symptoms. As a result, several clinical practice guidelines have been developed independently to help with detection and treatment of asymptomatic cardiomyopathy. These guidelines differ with regards to definitions of at-risk populations, surveillance modality and frequency, and recommendations for interventions. Differences between these guidelines could hinder the effective implementation of these recommendations. We report on the results of an international collaboration to harmonise existing cardiomyopathy surveillance recommendations using an evidence-based approach that relied on standardised definitions for outcomes of interest and transparent presentation of the quality of the evidence. The resultant recommendations were graded according to the quality of the evidence and the potential benefit gained from early detection and intervention.
Collapse
Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, USA.
| | - Melissa M Hudson
- Departments of Oncology and Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Renee L Mulder
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Ming Hui Chen
- Department of Pediatrics, Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Mary Dwyer
- Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Paul C Nathan
- The Hospital for Sick Children and the University of Toronto, Department of Pediatrics and Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - Wim J E Tissing
- Division of Pediatric Oncology and Pediatric Hematology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sadhna Shankar
- Division of Oncology, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA
| | - Elske Sieswerda
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Rod Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital and University of Newcastle, Newcastle upon Tyne, UK
| | - Julia Steinberger
- Department of Pediatrics, Division of Cardiology, University of Minnesota Amplatz Childrens' Hospital, Minneapolis, MN, USA
| | - Elvira C van Dalen
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Helena van der Pal
- Department of Pediatric Oncology and Medical Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - W Hamish Wallace
- Department of Hematology/Oncology, Royal Hospital for Sick Children, Edinburgh, Scotland
| | - Gill Levitt
- Department of Oncology/Haematology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Leontien C M Kremer
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| |
Collapse
|
31
|
Leger K, Slone T, Lemler M, Leonard D, Cochran C, Bowman WP, Bashore L, Winick N. Subclinical cardiotoxicity in childhood cancer survivors exposed to very low dose anthracycline therapy. Pediatr Blood Cancer 2015; 62:123-7. [PMID: 25176022 DOI: 10.1002/pbc.25206] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/10/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Subclinical cardiotoxicity occurs in childhood cancer survivors following moderate and high anthracycline doses. However, less is known about the subclinical changes in left ventricular (LV) structure that occur after very low anthracycline doses of ≤ 100 mg/m(2). This study was designed to assess LV function and key structural parameters following very low doses of anthracycline. PROCEDURE Conventional 2-dimensional echocardiograms with Doppler were obtained in 91 survivors of childhood cancer exposed to ≤ 100 mg/m(2), an average of 9.8 years from diagnosis. LV structural measurements were converted into Z-scores. The Z-score distributions were compared to those of the normal population. Diastolic and systolic function were quantified. RESULTS The cohort demonstrated a decreased posterior wall thickness (mean Z-score -1.01) and mildly decreased LV end diastolic (mean Z-score -0.85) and systolic (mean Z-score -0.84) dimensions compared to the normal population (P < 0.001). Further, 28% of patients (n = 25) had abnormal LV posterior wall thickness, ≥ 2 standard deviations below the mean (Z-score ≤ -2). There were no patients with diastolic dysfunction or symptomatic systolic dysfunction, however four patients demonstrated abnormal SF ≤ 28%. CONCLUSIONS A significant proportion of patients exposed to very low doses of anthracycline demonstrate subclinical abnormalities in LV structure, despite the absence of radiation or other risk factors. While we cannot say whether these structural changes will result in clinically significant cardiac disease, the reported progressive nature of these findings raises concern that there may truly be no safe dose of anthracycline.
Collapse
Affiliation(s)
- Kasey Leger
- Department of Pediatrics, Division of Pediatric Hematology, Oncology, University of Washington, Seattle, Washington
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Gibson TM, Robison LL. Impact of Cancer Therapy-Related Exposures on Late Mortality in Childhood Cancer Survivors. Chem Res Toxicol 2014; 28:31-7. [PMID: 25474125 DOI: 10.1021/tx500374k] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Survival of children and adolescents diagnosed with cancer has improved dramatically in recent decades, but the substantial burden of late morbidity and mortality (i.e., more than 5 years after cancer diagnosis) associated with pediatric cancer treatments is increasingly being recognized. Progression or recurrence of the initial cancer is a primary cause of death in the initial postdiagnosis period, but as survivors age, there is a dramatic shift in the cause-specific mortality profile. By 15 years postdiagnosis, the death rate attributable to health-related causes other than recurrence or external causes (e.g., accidents, suicide, assault) exceeds that due to primary disease, and by 30 years, these causes account for the largest proportion of cumulative mortality. The two most prominent causes of treatment-related mortality in childhood cancer survivors are subsequent malignant neoplasms and cardiovascular problems, the incidence of which can be largely attributed to the long-term toxicities of radiation and chemotherapy exposures. These late effects of treatment are likely to increase in importance as survivors continue to age, inspiring continued research to better understand their etiology and to inform early detection or prevention efforts.
Collapse
Affiliation(s)
- Todd M Gibson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital , Memphis, Tennessee 38105, United States
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital , Memphis, Tennessee 38105, United States
| |
Collapse
|
33
|
|
34
|
Lipshultz SE, Diamond MB, Franco VI, Aggarwal S, Leger K, Santos MV, Sallan SE, Chow EJ. Managing chemotherapy-related cardiotoxicity in survivors of childhood cancers. Paediatr Drugs 2014; 16:373-89. [PMID: 25134924 PMCID: PMC4417358 DOI: 10.1007/s40272-014-0085-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the US, children diagnosed with cancer are living longer, but not without consequences from the same drugs that cured their cancer. In these patients, cardiovascular disease is the leading cause of non-cancer-related morbidity and mortality. Although this review focuses on anthracycline-related cardiomyopathy in childhood cancer survivors, the global lifetime risk of other cardiovascular diseases such as atherosclerosis, arrhythmias and intracardiac conduction abnormalities, hypertension, and stroke also are increased. Besides anthracyclines, newer molecularly targeted agents, such as vascular endothelial growth factor receptor and tyrosine kinase inhibitors, also have been associated with acute hypertension, cardiomyopathy, and increased risk of ischemic cardiac events and arrhythmias, and are summarized here. This review also covers other risk factors for chemotherapy-related cardiotoxicity (including both modifiable and non-modifiable factors), monitoring strategies (including both blood and imaging-based biomarkers) during and following cancer treatment, and discusses the management of cardiotoxicity (including prevention strategies such as cardioprotection by use of dexrazoxane).
Collapse
Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine and the Children's Research Center of Michigan at the Children's Hospital of Michigan, 3901 Beaubien Boulevard, Suite 1K40, Detroit, MI, 48201, USA,
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Abstract
Pediatricians play a key role in helping prepare patients and families for anesthesia and surgery. The questions to be answered by the pediatrician fall into 2 categories. The first involves preparation: is the patient in optimal medical condition for surgery, and are the patient and family emotionally and cognitively ready for surgery? The second category concerns logistics: what communication and organizational needs are necessary to enable safe passage through the perioperative process? This revised statement updates the recommendations for the pediatrician's role in the preoperative preparation of patients.
Collapse
|
36
|
|
37
|
Armenian SH, Gelehrter SK, Vase T, Venkatramani R, Landier W, Wilson KD, Herrera C, Reichman L, Menteer JD, Mascarenhas L, Freyer DR, Venkataraman K, Bhatia S. Screening for cardiac dysfunction in anthracycline-exposed childhood cancer survivors. Clin Cancer Res 2014; 20:6314-23. [PMID: 24947931 DOI: 10.1158/1078-0432.ccr-13-3490] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE To examine the utility and reliability of obtaining early echocardiographic measurements of left ventricular (LV) remodeling as well as blood biomarkers of cardiac injury in asymptomatic childhood cancer survivors at risk for LV dysfunction and congestive heart failure due to past exposure to anthracycline chemotherapy. EXPERIMENTAL DESIGN Using a cross-sectional design, anthracycline-exposed childhood cancer survivors with preserved ejection fraction (EF; ≥50%) were evaluated using early echocardiographic indices and blood biomarkers of LV dysfunction. Survivors treated with ≥300 mg/m(2) anthracyclines [high risk (HR): n = 100] were compared with those treated with <300 mg/m(2) anthracyclines [low risk (LR): n = 50] and matched healthy controls (HC: n = 50). All echocardiograms were interpreted by an institutional cardiologist and a study cardiologist blinded to risk status. RESULTS Time from diagnosis was comparable for HR (12.0 years) and LR (13.2 years, P = 0.8) survivors. Echocardiograms: HR had lower LV thickness-dimension ratio (Z-score: HR: -0.62, LR: -0.03, HC: -0.02; P < 0.001), increased LV wall stress (HR: 66.7 g/cm(2), LR: 56.6 g/cm(2), HC: 54.2 g/cm(2); P < 0.01), and higher myocardial performance index (HR: 0.51, LR: 0.46, HC: 0.46; P < 0.01). Interobserver correlation (clinical/blinded reading) for all echocardiographic indices was excellent (range: R = 0.76-0.97, P < 0.001). Blood biomarkers: With the exception of NT-proBNP (r = 0.28, P < 0.01), there was no correlation between blood biomarkers (B-type natriuretic peptide, Troponin-T, ST-2, Galectin-3) and LV dysfunction. CONCLUSION Childhood cancer survivors with preserved EF 10+ years from anthracycline exposure had dose-dependent changes in echocardiographic markers of LV dysfunction.
Collapse
Affiliation(s)
- Saro H Armenian
- Division of Outcomes Research, Department of Population Sciences;
| | - Sarah K Gelehrter
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Tabitha Vase
- Division of Outcomes Research, Department of Population Sciences
| | - Rajkumar Venkatramani
- Hematology, Oncology, Blood & Marrow Transplantation and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Wendy Landier
- Division of Outcomes Research, Department of Population Sciences
| | - Karla D Wilson
- Division of Outcomes Research, Department of Population Sciences
| | - Claudia Herrera
- Division of Outcomes Research, Department of Population Sciences
| | - Leah Reichman
- Hematology, Oncology, Blood & Marrow Transplantation and
| | - John-David Menteer
- Cardiology, Children's Hospital Los Angeles, Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Leo Mascarenhas
- Hematology, Oncology, Blood & Marrow Transplantation and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - David R Freyer
- Hematology, Oncology, Blood & Marrow Transplantation and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | | | - Smita Bhatia
- Division of Outcomes Research, Department of Population Sciences
| |
Collapse
|
38
|
Noncancer-related mortality risks in adult survivors of pediatric malignancies: the childhood cancer survivor study. J Cancer Surviv 2014; 8:460-71. [PMID: 24719269 DOI: 10.1007/s11764-014-0353-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 03/11/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE We sought to identify factors, other than cancer-related treatment and presence/severity of chronic health conditions, which may be associated with late mortality risk among adult survivors of pediatric malignancies. METHODS Using the Childhood Cancer Survivor Study cohort and a case-control design, 445 participants who died from causes other than cancer recurrence/progression or non-health-related events were compared with 7,162 surviving participants matched for primary diagnosis, age at baseline questionnaire, time from diagnosis to baseline questionnaire, and time at-risk. Odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated for overall/cause-specific mortality. Independent measures included number/severity of chronic conditions, medical care, health-related behaviors, and health perceptions/concerns. RESULTS Adjusting for education, income, chemotherapy/radiation exposures, and number/severity of chronic health conditions, an increased risk for all-cause mortality was associated with exercising fewer than 3 days/week (OR = 1.72, CI 1.27-2.34), being underweight (OR = 2.58, CI 1.55-4.28), increased medical care utilization (P < 0.001), and self-reported fair to poor health (P < 0.001). Physical activity was associated with a higher risk of death among males (OR = 3.26, CI 1.90-5.61) reporting no exercise compared to those who exercised ≥3 times per week. Ever consuming alcohol was associated with a reduced risk of all-cause (OR = 0.61, CI 0.41-0.89) and other nonexternal causes of death (OR = 0.40, CI 0.20-0.79). Concerns/worries about future health (OR = 1.54, CI 1.10-2.71) were associated with increased all-cause mortality. CONCLUSIONS Factors independent of cancer treatment and chronic health conditions modify the risk of death among adult survivors of pediatric cancer. IMPLICATIONS FOR CANCER SURVIVORS Continued cohort observation may inform interventions to reduce mortality.
Collapse
|
39
|
Armenian SH, Gelehrter SK, Vase T, Venkatramani R, Landier W, Wilson KD, Herrera C, Reichman L, Menteer JD, Mascarenhas L, Freyer DR, Venkataraman K, Bhatia S. Carnitine and cardiac dysfunction in childhood cancer survivors treated with anthracyclines. Cancer Epidemiol Biomarkers Prev 2014; 23:1109-14. [PMID: 24718281 DOI: 10.1158/1055-9965.epi-13-1384] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Childhood cancer survivors are at high risk of developing congestive heart failure (CHF) compared with the general population, and there is a dose-dependent increase in CHF risk by anthracycline dose. The mechanism by which this occurs has not been fully elucidated. Metabolomics, the comprehensive profile of small-molecule metabolites, has the potential to provide insight into the pathogenesis of disease states and discover diagnostic markers for therapeutic targets. We performed echocardiographic testing and blood plasma metabolomic analyses (8 pathways; 354 metabolites) in 150 asymptomatic childhood cancer survivors previously treated with anthracyclines. Median time from cancer diagnosis to study participation was 12.4 years (2.6-37.9 years); 64% were treated for a hematologic malignancy; median anthracycline dose was 350 mg/m(2) (25-642 mg/m(2)). Thirty-five (23%) participants had cardiac dysfunction-defined as left ventricular end-systolic wall stress >2SD by echocardiogram. Plasma levels of 15 compounds in three metabolic pathways (carbohydrate, amino acid, and lipid metabolism) were significantly different between individuals with cardiac dysfunction and those with normal systolic function. After adjusting for multiple comparisons, individuals with cardiac dysfunction had significantly lower plasma carnitine levels [relative ratio (RR), 0.89; P < 0.01] in relation to those with normal systolic function. These findings may facilitate the development of primary prevention (treatment of carnitine deficiency before/during anthracycline administration) and secondary prevention strategies (screening and treatment in long-term survivors) in patients at highest risk for CHF. Cancer Epidemiol Biomarkers Prev; 23(6); 1109-14. ©2014 AACR.
Collapse
Affiliation(s)
- Saro H Armenian
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Sarah K Gelehrter
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Tabitha Vase
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Rajkumar Venkatramani
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MichiganAuthors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Wendy Landier
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Karla D Wilson
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Claudia Herrera
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Leah Reichman
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - John-David Menteer
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MichiganAuthors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Leo Mascarenhas
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MichiganAuthors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - David R Freyer
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MichiganAuthors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Kalyanasundaram Venkataraman
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Smita Bhatia
- Authors' Affiliations: Division of Outcomes Research, Department of Population Sciences, Department of Cardiology, City of Hope, Duarte; Divisions of Hematology, Oncology, and Blood & Marrow Transplantation and Cardiology, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
40
|
Zinzani PL, Federico M, Oliva S, Pinto A, Rigacci L, Specchia G, Tucci A, Vitolo U. The more patients you treat, the more you cure: managing cardiotoxicity in the treatment of aggressive non-Hodgkin lymphoma. Leuk Lymphoma 2014; 56:12-25. [DOI: 10.3109/10428194.2014.894187] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
41
|
Assessment of early-onset chronic progressive anthracycline cardiotoxicity in children: different response patterns of right and left ventricles. Pediatr Cardiol 2014; 35:82-8. [PMID: 23821296 DOI: 10.1007/s00246-013-0745-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022]
Abstract
We aimed to assess early-onset chronic progressive cardiotoxicity in the left and right ventricles with increasing cumulative anthracycline doses. We evaluated 72 patients within the first year after doxorubicin and/or daunorubicin treatment (median 1.3 months; range 0.3-11.5) and 31 healthy controls. Pretreatment and posttreatment QT interval analyzes were performed in 27 newly diagnosed patients. The echocardiographic data of all examinations of 72 patients were classified into three groups according to instant cumulative anthracycline doses: treatment group (TG)-I (≤120 mg/m(2); n = 26), TG-II (120-240 mg/m(2); n = 39), and TG-III (≥240 mg/m(2); n = 40). Diastolic and systolic parameters were analyzed by conventional echocardiography and tissue Doppler imaging (TDI) and compared with those of healthy controls. The mean age for patients and controls was 8.2 ± 4.5 and 9.6 ± 4.2 years, respectively (p > 0.05). QTc dispersion significantly increased after anthracycline treatment (p = 0.02). TDI showed decreased E' velocity (p < 0.001) and E'/A' ratio (p < 0.001) at lateral tricuspid annulus segment in TG-I, and these findings continued in TG-II and -III. In addition, S' velocity decreased in TG-I, -II, and -III at lateral mitral annulus (10.5 ± 2.6 cm/s, p < 0.05; 9.9 ± 2.2 cm/s, p < 0.001; and 10.1 ± 2.3 cm/s, p < 0.01, respectively). However, decrease in left-ventricular ejection fraction was statistically significant in TG-II and -III (p < 0.001). Although myocardial performance index was significantly increased in all treatment groups in both segments, it was primarily due to significant increases in isovolumic relaxation time at the lateral tricuspid annulus and isovolumic contraction time at the lateral mitral annulus. Abnormalities in diastolic function in right ventricle and systolic function in the left ventricle were observed even with a cumulative anthracycline dose <120 mg/m(2) by TDI. In addition, anthracycline treatment led to an increase in QTc dispersion.
Collapse
|
42
|
Lotrionte M, Biondi-Zoccai G, Abbate A, Lanzetta G, D'Ascenzo F, Malavasi V, Peruzzi M, Frati G, Palazzoni G. Review and meta-analysis of incidence and clinical predictors of anthracycline cardiotoxicity. Am J Cardiol 2013; 112:1980-4. [PMID: 24075281 DOI: 10.1016/j.amjcard.2013.08.026] [Citation(s) in RCA: 236] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/06/2013] [Accepted: 08/06/2013] [Indexed: 02/08/2023]
Abstract
The management of individual patients requiring anthracyclines remains challenging because uncertainty persists on predictors of cardiotoxicity. We aimed to perform a systematic review and meta-analysis on incidence and predictors of anthracycline chemotherapy in patients with cancer. Databases were searched for pertinent studies. Meta-analytic pooling with random-effects methods was performed for incidence estimates, while relying on descriptive statistics for prevalence and strength of association of predictors. From 16,054 retrieved citations, 18 studies reporting on 49,017 patients with cancer were included, with 22,815 treated with anthracyclines. After a median follow-up of 9 years, clinically overt cardiotoxicity occurred in 6% (95% confidence interval 3% to 9%), whereas subclinical cardiotoxicity developed in 18% (95% confidence interval 12% to 24%). Appraisal of independent risk factors of cardiotoxicity showed that cumulative anthracycline dose was most consistently reported as an accurate and robust predictor of cardiotoxicity, with an acceptable prognostic role also for chest radiotherapy, African-American ethnicity, very young or very old age, diabetes, hypertension, very high or very low body weight, or severe co-morbidities. In conclusion, despite ongoing refinements in chemotherapy regimens, anthracyclines still pose a significant risk of cardiotoxicity, especially in those requiring a high cumulative dose or chest radiotherapy.
Collapse
|
43
|
Smith WA, Ness KK, Joshi V, Hudson MM, Robison LL, Green DM. Exercise training in childhood cancer survivors with subclinical cardiomyopathy who were treated with anthracyclines. Pediatr Blood Cancer 2013; 61:10.1002/pbc.24850. [PMID: 24623535 PMCID: PMC4167576 DOI: 10.1002/pbc.24850] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 10/15/2013] [Indexed: 01/14/2023]
Abstract
Childhood cancer survivors (CCS) treated with anthracyclines are at risk for cardiomyopathy. This case series evaluated the response of anthracycline exposed CCS with subclinical cardiomyopathy to aerobic and strength training. Body composition, strength and cardiopulmonary fitness were evaluated before and after the 12-week intervention. All equipment and materials were provided to five 10+ year CCS (3 males, mean age 38.0 ± 3.3 years) for a guideline-based home exercise program. All five completed the study with no adverse events. Compliance with exercise was 86%. These results suggest that exercise training may improve exercise capacity of CCS with subclinical cardiomyopathy. Pediatr Blood Cancer. © 2013 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Webb A. Smith
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Vijaya Joshi
- The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Daniel M. Green
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| |
Collapse
|
44
|
Sharkey LC, Radin MJ, Heller L, Rogers LK, Tobias A, Matise I, Wang Q, Apple FS, McCune SA. Differential cardiotoxicity in response to chronic doxorubicin treatment in male spontaneous hypertension-heart failure (SHHF), spontaneously hypertensive (SHR), and Wistar Kyoto (WKY) rats. Toxicol Appl Pharmacol 2013; 273:47-57. [DOI: 10.1016/j.taap.2013.08.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 07/28/2013] [Accepted: 08/10/2013] [Indexed: 12/20/2022]
|
45
|
Abstract
Treatment advances and higher participation rates in clinical trials have rapidly increased the number of survivors of childhood cancer. However, chemotherapy and radiation treatments are cardiotoxic and can cause cardiomyopathy, conduction defects, myocardial infarction, hypertension, stroke, pulmonary oedema, dyspnoea and exercise intolerance later in life. These cardiotoxic effects are often progressive and irreversible, emphasizing a need for effective prevention and treatment to reduce or avoid cardiotoxicity. Medical interventions, such as angiotensin-converting enzyme inhibitors, β-blockers, and growth hormone therapy, might be used to treat cardiotoxicity in childhood cancer survivors. Preventative strategies should include the use of dexrazoxane, which provides cardioprotection without reducing the oncological efficacy of doxorubicin chemotherapy; less-toxic anthracycline derivatives and the use of antioxidant nutritional supplements might also be beneficial. Continuous-infusion doxorubicin provides no benefit over bolus infusion in children. Identifying patient-related (for example, obesity and hypertension) and drug-related (for example, cumulative dose) risk factors for cardiotoxicity could help tailor treatments to individual patients. However, all survivors of childhood cancer are at increased risk of cardiotoxicity, suggesting that survivor screening recommendations for assessment of global risk of premature cardiovascular disease should apply to all survivors. Optimal, evidence-based monitoring strategies and multiagent preventative treatments still need to be identified.
Collapse
|
46
|
Lipshultz SE, Adams MJ, Colan SD, Constine LS, Herman EH, Hsu DT, Hudson MM, Kremer LC, Landy DC, Miller TL, Oeffinger KC, Rosenthal DN, Sable CA, Sallan SE, Singh GK, Steinberger J, Cochran TR, Wilkinson JD. Long-term cardiovascular toxicity in children, adolescents, and young adults who receive cancer therapy: pathophysiology, course, monitoring, management, prevention, and research directions: a scientific statement from the American Heart Association. Circulation 2013; 128:1927-95. [PMID: 24081971 DOI: 10.1161/cir.0b013e3182a88099] [Citation(s) in RCA: 374] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
47
|
Rai SN, Pan J, Yuan X, Sun J, Hudson MM, Srivastava DK. Estimating Incidence Rate on Current Status Data with Application to a Phase IV Cancer Trial. COMMUN STAT-THEOR M 2013. [DOI: 10.1080/03610926.2011.620208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
48
|
Educational paper: decreasing the burden of cardiovascular disease in childhood cancer survivors: an update for the pediatrician. Eur J Pediatr 2013; 172:1149-60. [PMID: 23361962 DOI: 10.1007/s00431-013-1931-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 01/08/2013] [Indexed: 12/31/2022]
Abstract
The cardiovascular impact of cancer therapies on the heart is one of the major concerns in the long-term follow-up of childhood cancer survivors (CCSs). Long-term cardiovascular effects include the development of left ventricular dysfunction resulting in congestive heart failure and ischemic heart disease, as well as valvular and pericardial disease. This is mainly ascribed to the cardiotoxic side effects of chemotherapeutic agents (especially anthracyclines) and radiotherapy, but other factors such as radiation and inflammation play a role in the effect of childhood cancer on the cardiovascular health. The most concerning effect is the high incidence of symptomatic heart failure in CCS patients treated with anthracyclines. More than 50 % of CCSs treated with anthracyclines develop asymptomatic left ventricular dysfunction after cancer therapy, with approximately 5 % developing clinical signs of heart failure during long-term follow-up. Once CCS patients develop congestive heart failure, prognosis is poor and is not influenced by current medical treatment strategies. To reduce the long-term burden of cardiovascular disease in pediatric cancer patients, a diversified approach will be necessary. In the acute phase, prevention of cardiac damage through the use of cardioprotective agents (e.g., dexrazoxane) or by administering less cardiotoxic chemotherapeutic agents is to be considered. A recent randomized trial suggested that the use of dexrazoxane reduced cardiac toxicity without affecting cancer outcomes. Especially patients requiring high doses of chemotherapeutic agents could benefit from this approach. Recent data suggest that genetic testing might identify patients at higher risk for cardiotoxicity. This seems mainly related to genes involved in drug metabolism. This would allow personalized approach adjusting chemotherapy based on cardiovascular risk profiling. This could be combined with newer monitoring strategies in the acute phase using newer echocardiographic techniques and biomarker screening to identify patients with early damage to the myocardium. For the long-term CCS cohort, early detection and treatment of early dysfunction prior to the development of congestive heart failure could potentially improve long-term outcomes. Promoting healthy lifestyles and controlling additional cardiovascular risk factors (e.g., obesity, diabetes, arterial hypertension) is an important task for every physician involved in the care of this growing cohort.
Collapse
|
49
|
Arslan D, Cihan T, Kose D, Vatansev H, Cimen D, Koksal Y, Oran B, Akyurek F. Growth-differentiation factor-15 and tissue doppler ımaging in detection of asymptomatic anthracycline cardiomyopathy in childhood cancer survivors. Clin Biochem 2013; 46:1239-43. [PMID: 23850849 DOI: 10.1016/j.clinbiochem.2013.06.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 06/17/2013] [Accepted: 06/26/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Anthracyclines have led to an increased risk of cardiac morbidity and mortality. Late cardiac complications in cancer survivors may develop from subclinical myocardial damage. Tissue Doppler imaging (TDI) also has potential as a clinically useful technique for the assessment of myocardial function. Biochemical markers may be used to detect cardiac damage growth-differentiation factor-15 (GDF-15) and are emerging as a biomarker of cardiac dysfunction. The aim of this study is to assess the value of the plasma levels of GDF-15 and TDI in detecting late myocardial dysfunction in childhood cancer survivors (CCS) who were treated with anthracyclines. DESIGN AND METHODS Thirty-eight CCS who had completed chemotherapy treatment with anthracyclines were included in this study. Control group consisted of 32 age- and gender-matched healthy volunteers. All children underwent a detailed echocardiography, which contained an M-mode, pulse Doppler and tissue Doppler imaging. However, GDF-15 and cardiac troponin-I (cTnI) were measured. RESULTS Although, systolic function of the left ventricular was similar in all groups, there were significant differences between parameters of diastolic function of the heart. The mitral valve E wave, E/A ratio, left ventricular E'm wave, and E'm/A'm ratio were different in the patients than in the controls (p = 0.049, p = 0.037, p < 0.0001, p = 0.001, respectively). The tricuspid valve E/A ratio, right ventricular E't wave, and E't/A't ratio in the patients were also different from those of the controls (p = 0.031, p < 0.0001, p < 0.0001, respectively). Mean plasma GDF-15 was significantly higher in patients than healthy controls (p = 0.027). There were no significant differences in cTnI between both groups. CONCLUSIONS Growth-differentiation factor-15 level may be used as a biomarker of anthracycline-induced cardiovascular disease severity in the CCS.
Collapse
Affiliation(s)
- Derya Arslan
- Selcuk University Medical Faculty, Department of Pediatric Cardiology, Konya, Turkey.
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Minotti G. Pharmacology at work for cardio-oncology: ranolazine to treat early cardiotoxicity induced by antitumor drugs. J Pharmacol Exp Ther 2013; 346:343-9. [PMID: 23818683 DOI: 10.1124/jpet.113.204057] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Antitumor drugs may cause asymptomatic diastolic dysfunction that introduces a lifetime risk of heart failure or myocardial infarction. Cardio-oncology is the discipline committed to the cardiac surveillance and management of cancer patients and survivors; however, cardio-oncology teams do not always attempt to treat early diastolic dysfunction. Common cardiovascular drugs, such as β blockers or angiotensin-converting enzyme inhibitors or others, would be of uncertain efficacy in diastolic dysfunction. This perspective describes the potential value of ranolazine, an antianginal drug that improves myocardial perfusion by relieving diastolic wall tension and dysfunction. Ranolazine acts by inhibiting the late inward sodium current, and pharmacological reasonings anticipate that antitumor anthracyclines and nonanthracycline chemotherapeutics might well induce anomalous activation of this current. These notions formed the rationale for a clinical study of the efficacy and safety of ranolazine in cancer patients. This study was not designed to demonstrate that ranolazine reduced the lifetime risk of cardiac events; it was designed as a short term proof-of-concept study that probed the following hypotheses: 1) asymptomatic diastolic dysfunction could be detected a few days after patients completed antitumor therapy, and 2) ranolazine was active and safe in relieving echocardiographic and/or biohumoral indices of diastolic dysfunction, measured at 5 weeks or 6 months of ranolazine administration. These facts illustrate the translational value of pharmacology, which goes from identifying therapeutic opportunities to validating hypotheses in clinical settings. Pharmacology is a key to the success of cardio-oncology.
Collapse
Affiliation(s)
- Giorgio Minotti
- CIR and Drug Sciences, University Campus Bio-Medico, Rome, Italy.
| |
Collapse
|