Cancer Therapeutics-Related Cardiac Dysfunction - Insights From Bench and Bedside of Onco-Cardiology

Shared and Reciprocal Mechanisms Between Heart Failure and Cancer - An Emerging Concept of Heart-Cancer Axis

Epidemiological evidence of increased risks of cancer in heart failure (HF) patients and HF in cancer patients has suggested close relationships between the pathogenesis of both diseases. Indeed, HF and cancer share common risk factors, including aging and unhealthy lifestyles, and underlying mechanisms, including activation of the sympathetic nervous system and renin-angiotensin-aldosterone system, chronic inflammation, and clonal hematopoiesis of indeterminate potential. Mechanistically, HF accelerates cancer development and progression via secreted factors, so-called cardiokines, and epigenetic remodeling of bone marrow cells into an immunosuppressive phenotype. Reciprocally, cancer promotes HF via cachexia-related wasting and metabolic remodeling in the heart, and possibly via cancer-derived extracellular vesicles influencing myocardial structure and function. The novel concept of the "heart-cancer axis" will help in our understanding of the shared and reciprocal relationships between HF and cancer, and provide innovative diagnostic and therapeutic approaches for both diseases.

Annual Increase of Acute Inpatients with Both Cancer and Cardiovascular Diseases in Japan 2011-2015: Analysis From National Database of Health Insurance Claims and Specific Health Checkups of Japan

BACKGROUND

Patients with cancer were able to live longer due to improvements in cancer treatment. Additionally, cardiovascular disease (CVD) is the second leading cause of mortality in cancer survivors. However, epidemiological data on onco-CVD have not been sufficiently provided. We aimed to investigate the clinical characteristics of cancer in CVD patients using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB).

METHOD AND RESULTS

The NDB sampling dataset used in this study was randomly sampled 10% from the whole Diagnosis Procedure Combination (DPC) records from every January, April, July, and October from 2011 to 2015. The significance of the increase trend in the percentage of records in each disease group to the total number of all DPC records from 2011 to 2015 was checked with Chi-square test with a Bonferroni correction. The percentage of records in cancer with the CVD group to the total number of all DPC records significantly increased over time, and their average age also increased since 2011. Their proportion over 75 years was approximately 56 % in 2015. There was no difference in the cancer sites. However, the prevalence of heart failure dramatically elevated.

CONCLUSION

We were able to assess the increase in cancer among CVD patients using DPC inpatient records obtained from the NDB. Both cardiologists and oncologists should be more aware of this phenomenon.

Late-onset doxorubicin-induced congestive heart failure in an elderly cancer survivor: A case report

Background

Recently, the survival rate of patients with cancer has improved annually due to advancements in cancer diagnosis and treatment technologies. Meanwhile, late-onset complications associated with cancer treatment significantly affect survival and quality of life. However, different from pediatric cancer survivors, there is no unified view on the follow-up of late complications in elderly cancer survivors. We reported a case of congestive heart failure as a late-onset complication of doxorubicin (DXR) in an elderly cancer survivor.

Case report

The patient is an 80-year-old woman with hypertension and chronic renal failure. She received six cycles of chemotherapy for Hodgkin's lymphoma that started in January 201X-2. The total dose of DXR was 300 mg/m2, and a transthoracic echocardiogram (TTE) performed in October 201X-2, showed good left ventricular wall motion (LVWM). In April 201X, she suddenly developed dyspnea. Upon arrival at the hospital, a physical examination revealed orthopnea, tachycardia, and leg edema. A chest radiograph showed cardiac enlargement and pleural effusion. A TTE showed diffusely reduced LVWM and a left ventricular ejection fraction in the 20% range. After close examination, the patient was diagnosed with congestive heart failure due to late-onset DXR-induced cardiomyopathy.

Conclusion

Late-onset DXR-induced cardiotoxicity is considered high-risk from 250 mg/m2 or higher. Elderly cancer survivors are at higher risk of cardiotoxicity than non-elderly cancer survivors and may require closer follow-up.

NIR absorptive croconic acid/quercetin/CaO2 nanoplatform for tumor calcium overload therapy combined mild photothermal therapy

With excellent biocompatibility, stable chemical and optical properties, small organic molecules-based agents have always been a research hotspot in cancer photothermal therapy (PTT). In this work, a novel croconic acid-based molecule (CR) was designed and synthesized as an ideal photothermal agent (PTA), which showed abundant near-infrared (NIR) light absorption, high photothermal conversion ability, and excellent photothermal stability. By loading CR and quercetin (Qu) in CaO₂, and coated with DSPE-PEG₂₀₀₀, a multifunctional theranostic nanoparticle (CCQ) was successfully prepared for calcium overloading mitochondrial metabolism inhibition synergetic mild PTT. Upon entering tumor microenvironment, CCQ can produce abundant H₂O₂ and a large amount of calcium ions, which lead to the imbalance of calcium concentration in the internal environment of tumor cells and induced mitochondrial apoptosis. With the existence of Qu, CCQ can effectively inhibit the expression of heat shock proteins (Hsp) during the PTT process, which weaken the heat resistance of tumors, ablate tumors at lower temperature (~45 °C), and reduce the damage to normal tissues. Guided by photoacoustic imaging (PAI), CCQ showed excellent multimodal therapeutic effect of tumors. This study provided a novel CR organic molecule-based theranostic nanoplatform that can be used to treat tumors via calcium overload therapy synergetic PTT at safe temperatures, which has promising potential for the future clinical cancer treatment.

Ventricular Sigmoid Septum as a Risk Factor for Anthracycline-Induced Cancer Therapeutics-Related Cardiac Dysfunction in Patients With Malignant Lymphoma

Background: Identifying risk factors for cancer therapeutics-related cardiac dysfunction (CTRCD) is essential for the early detection and prompt initiation of medial therapy for CTRCD. No study has investigated whether the sigmoid septum is a risk factor for anthracycline-induced CTRCD.

Methods and Results: We enrolled 167 patients with malignant lymphoma who received a CHOP-like regimen from January 2008 to December 2017 and underwent both baseline and follow-up echocardiography. Patients with left ventricular ejection fraction (LVEF) ≤50% were excluded. CTRCD was defined as a ≥10% decline in LVEF and LVEF <50% after chemotherapy. The angle between the anterior wall of the aorta and the ventricular septal surface (ASA) was measured to quantify the sigmoid septum. CTRCD was observed in 36 patients (22%). Mean LVEF and global longitudinal strain (GLS) were lower, left ventricular mass index was higher, and ASA was smaller in patients with CTRCD. In a multivariable Cox proportional hazard analysis, GLS (hazard ratio [HR] per 1% decrease 1.20; 95% confidence interval [CI] 1.07–1.35) and ASA (HR per 1° increase 0.97; 95% CI 0.95–0.99) were identified as independent determinants of CTRCD. An integrated discrimination improvement evaluation confirmed the significant incremental value of ASA for developing CTRCD.

Conclusions: Smaller ASA was an independent risk factor and had significant incremental value for CTRCD in patients with malignant lymphoma who received the CHOP-like regimen.

Detection of Profound Myocardial Damage by Cardiac MRI in a Patient with Severe Cardiotoxicity Induced by Anti-HER2 Therapy

Anti-HER2 therapy has greatly improved the long-term prognosis of patients with HER2-positive breast cancer. Meanwhile, by interfering with the protective effects of neuregulin-1/HER2 signaling on stressed cardiomyocytes, anti-HER2 therapy occasionally induces reversible cancer therapeutics-related cardiac dysfunction (CTRCD). Cardiac magnetic resonance (CMR) parametric mapping or myocardial feature-tracking, in combination with late gadolinium enhancement (LGE) imaging, has the potential to detect changes in the myocardium in anti-HER2 therapy-related cardiac dysfunction. Here we report a breast cancer patient who experienced life-threatening CTRCD after treatment with trastuzumab plus pertuzumab. This case showed multiple transmural LGE-positive myocardial lesions in CMR imaging and high native T1 and T2 values in CMR parametric mapping, which was apparently more extensive than those observed in most patients with anti-HER2 therapy-related cardiac dysfunction. Consistent with profound myocardial damage indicated by CMR, her cardiac function was not fully restored despite intensive care and cardioprotective drug therapy. These findings suggest the potential usefulness of LGE imaging and parametric mapping by CMR for the assessment of myocardial injury to determine the clinical severity of anti-HER2 therapy-related cardiac dysfunction.

Cancer treatment-related cardiovascular disease: Current status and future research priorities

With the development of new drugs, such as molecular-targeted drugs, and multidisciplinary therapies, cancer treatment outcomes have improved, and the number of cancer survivors is increasing every year. However, some chemotherapeutic agents cause cardiovascular complications (cancer treatment-related cardiovascular disease, CTRCVD), which affect the life prognosis and quality of life (QOL) of cancer patients. Therefore, it is necessary to select treatment methods that take into account the prognosis and QOL of cancer patients, and to take measures against CTRCVD. The mechanism of cardiotoxicity of high-risk drugs, such as doxorubicin and HER2 inhibitors, are still unclear; genetic factors, and cardiovascular disease risk factors (e.g., hypertension, dyslipidemia, and diabetes) are associated with CTRCVD progression. The establishment of methods for prevention, early diagnosis, and treatment of CTRCVD and the generation of evidence for these methods are needed. It is also necessary to develop screening methods for chemotherapy cardiotoxicity. In this review, we discuss the current status of CTRCVD, its complications, and expected countermeasures.

Mechanisms and Management of Immune Checkpoint Inhibitor-Related Cardiac Adverse Events

Onco-cardiology recently emerged as a novel discipline to provide effective cardioprotective care against cancer therapeutics-related cardiac adverse events (CAEs) and support the continuity of optimal cancer treatment. Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy and dramatically improved outcomes in patients with advanced or refractory cancers. However, ICIs intrinsically stimulate systemic immune responses and can potentially induce a spectrum of immune-related adverse events (irAEs), which can affect any organs of the body. The manifestation of cardiac irAEs includes myocarditis, arrhythmias and conduction abnormalities, and pericardial diseases. Takotsubo-like cardiomyopathy is also included as a manifestation of ICI-related CAEs, but the pathophysiological relevance is unclear. Although the incidence is rare, ICI-related CAEs are life-threatening and potentially fatal. Elucidating pathophysiology and establishing management measures of ICI-related CAEs are one of the most urgent challenges in the field of onco-cardiology.