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Delombaerde D, Vulsteke C, Van de Veire N, Vervloet D, Moerman V, Van Calster L, Willems AM, Croes L, Gremonprez F, De Meulenaere A, Elzo Kraemer X, Wouters K, Peeters M, Prenen H, De Sutter J. Close Cardiovascular Monitoring during the Early Stages of Treatment for Patients Receiving Immune Checkpoint Inhibitors. Pharmaceuticals (Basel) 2024; 17:965. [PMID: 39065813 PMCID: PMC11279915 DOI: 10.3390/ph17070965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/09/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024] Open
Abstract
Background: There is an unmet medical need for the early detection of immune checkpoint inhibitor (ICI)-induced cardiovascular (CV) adverse events due to a lack of adequate biomarkers. This study aimed to provide insights on the incidence of troponin elevations and echocardiographic dynamics during ICI treatment in cancer patients and their role as potential biomarkers for submyocardial damage. In addition, it is the first study to compare hs-TnT and hs-TnI in ICI-treated patients and to evaluate their interchangeability in the context of screening. Results: Among 59 patients, the mean patient age was 68 years, and 76% were men. Overall, 25% of patients received combination therapy. Although 10.6% [95% CI: 5.0-22.5] of the patients developed troponin elevations, none experienced a CV event. No significant changes were found in 3D left ventricular (LV) ejection fraction nor in global longitudinal strain f (56 ± 6% vs. 56 ± 6%, p = 0.903 and -17.8% [-18.5; -14.2] vs. -17.0% [-18.8; -15.1], p = 0.663) at 3 months. There were also no significant changes in diastolic function and right ventricular function. In addition, there was poor agreement between hs-TnT and hs-TnI. Methods: Here, we present a preliminary analysis of the first 59 patients included in our ongoing prospective clinical trial (NCT05699915) during the first three months of treatment. All patients underwent electrocardiography and echocardiography along with blood sampling at standardized time intervals. This study aimed to investigate the incidence of elevated hs-TnT levels within the first three months of ICI treatment. Elevations were defined as hs-TnT above the upper limit of normal (ULN) if the baseline value was normal, or 1.5 ≥ times baseline if the baseline value was above the ULN. Conclusions: Hs-TnT elevations occurred in 10.6% of the patients. However, no significant changes were found on 3D echocardiography, nor did any of the patients develop a CV event. There were also no changes found in NT-proBNP. The study is still ongoing, but these preliminary findings do not show a promising role for cardiac troponins nor for echocardiographic dynamics in the prediction of CV events during the early stages of ICI treatment.
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Affiliation(s)
- Danielle Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium; (C.V.); (F.G.); (A.D.M.); (X.E.K.)
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium; (L.C.); (M.P.); (H.P.)
| | - Christof Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium; (C.V.); (F.G.); (A.D.M.); (X.E.K.)
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium; (L.C.); (M.P.); (H.P.)
| | - Nico Van de Veire
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium; (N.V.d.V.); (D.V.); (V.M.); (L.V.C.); (A.-M.W.); (J.D.S.)
- Department of Cardiology, Free University Brussels, 1000 Brussels, Belgium
| | - Delphine Vervloet
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium; (N.V.d.V.); (D.V.); (V.M.); (L.V.C.); (A.-M.W.); (J.D.S.)
| | - Veronique Moerman
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium; (N.V.d.V.); (D.V.); (V.M.); (L.V.C.); (A.-M.W.); (J.D.S.)
| | - Lynn Van Calster
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium; (N.V.d.V.); (D.V.); (V.M.); (L.V.C.); (A.-M.W.); (J.D.S.)
| | - Anne-Marie Willems
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium; (N.V.d.V.); (D.V.); (V.M.); (L.V.C.); (A.-M.W.); (J.D.S.)
| | - Lieselot Croes
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium; (L.C.); (M.P.); (H.P.)
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Félix Gremonprez
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium; (C.V.); (F.G.); (A.D.M.); (X.E.K.)
| | - Astrid De Meulenaere
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium; (C.V.); (F.G.); (A.D.M.); (X.E.K.)
| | - Ximena Elzo Kraemer
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium; (C.V.); (F.G.); (A.D.M.); (X.E.K.)
| | - Kristien Wouters
- Antwerp University Hospital, Clinical Trial Center (CTC), CRC Antwerp, 2650 Edegem, Belgium;
| | - Marc Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium; (L.C.); (M.P.); (H.P.)
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Hans Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium; (L.C.); (M.P.); (H.P.)
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Johan De Sutter
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium; (N.V.d.V.); (D.V.); (V.M.); (L.V.C.); (A.-M.W.); (J.D.S.)
- Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
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Zhuang Y, An Q, Wang F, Han D, Qiao Z, Jiang Q, Liu M, Li Y, Shangguan J, Bi X, Shen D. The role of circulating biomarkers in predicting the 30-day mortality of immune checkpoint inhibitors-related myocarditis: a retrospective cohort study. Intern Emerg Med 2024; 19:377-389. [PMID: 38085435 DOI: 10.1007/s11739-023-03481-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/07/2023] [Indexed: 03/21/2024]
Abstract
Immune checkpoint inhibitors-related myocarditis (ICIs-M) is a rare and highly lethal immune-related adverse events (irAEs) in common irAEs. This study aims to find circulating biomarkers that can reflect disease state and prognosis accurately. 48 patients with ICIs-M were enrolled according to the diagnostic criteria for ICIs-related myocarditis. For all enrolled patients, valuable information was extracted retrospectively from the medical system, mainly including demographic information, tumor information and laboratory examination. The follow-up period was defined as 30 days after the first diagnosis of ICIs-M. In this study, the 30-day mortality rate of ICIs-M was 24.4%. After adjusting for potential confounding factors using multivariate analysis tools, we demonstrated the excellent performance of biomarkers in predicting 30-day mortality in patients with ICIs-M, including PLT (hazard ratio (HR), 1.07; 95% confidence interval (95%CI), 1.01-1.14; p = 0.028), ALT (HR, 1.23; 95%CI, 1.06-1.41; p = 0.005), AST(HR, 1.06; 95%CI, 1.01-1.10; p = 0.015), LDH (HR, 1.15; 95%CI, 1.04-1.26; p = 0.004), troponin I(HR, 1.44; 95%CI, 1.09-1.89; p = 0.009), PLR (blood plate/lymphocyte) (HR, 1.04; 95% CI, 1.01-1.07; p = 0.024), LAR (lactate dehydrogenase/albumin) (HR, 1.05; 95%CI, 1.01-1.09; p = 0.012), and AAR (aspartate transaminase/albumin) (HR, 1.18; 95%CI, 1.00-1.39; p = 0.048). The analysis of the receiver operating characteristic showed that biomarkers with area under curve (AUC) greater than or equal to 0.80 were LDH (cutoff value, 724.5; AUC, 0.86; 95%CI, 0.75-0.97), LAR (cutoff value, 18.11; AUC, 0.87; 95%CI, 0.76-0.97), troponin I (cutoff value, 0.87; AUC, 0.80; 95%CI, 0.62-0.99), and AAR(cutoff value, 1.52; AUC, 0.80; 95%CI, 0.61-0.98). LDH, LAR, troponin I, and AAR are a group of promising biomarkers that demonstrate excellent predictive ability in predicting the 30-day mortality rate of immune-related myocarditis.
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Affiliation(s)
- Yuansong Zhuang
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Quanxu An
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Fuhang Wang
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dongjian Han
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Zhentao Qiao
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Qingjiao Jiang
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Miaomiao Liu
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yuhang Li
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Jiahong Shangguan
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xuanye Bi
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Deliang Shen
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China.
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Quagliariello V, Passariello M, Bisceglia I, Paccone A, Inno A, Maurea C, Rapuano Lembo R, Manna L, Iovine M, Canale ML, Scherillo M, Ascierto PA, Gabrielli D, De Lorenzo C, Maurea N. Combinatorial immune checkpoint blockade increases myocardial expression of NLRP-3 and secretion of H-FABP, NT-Pro-BNP, interleukin-1β and interleukin-6: biochemical implications in cardio-immuno-oncology. Front Cardiovasc Med 2024; 11:1232269. [PMID: 38322766 PMCID: PMC10844473 DOI: 10.3389/fcvm.2024.1232269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 01/10/2024] [Indexed: 02/08/2024] Open
Abstract
Background Immune checkpoint blockade in monotherapy or combinatorial regimens with chemotherapy or radiotherapy have become an integral part of oncology in recent years. Monoclonal antibodies against CTLA-4 or PD-1 or PDL-1 are the most studied ICIs in randomized clinical trials, however, more recently, an anti-LAG3 (Lymphocyte activation gene-3) antibody, Relatlimab, has been approved by FDA in combination with Nivolumab for metastatic melanoma therapy. Moreover, Atezolizumab is actually under study in association with Ipilimumab for therapy of metastatic lung cancer. Myocarditis, vasculitis and endothelitis are rarely observed in these patients on monotherapy, however new combination therapies could expose patients to more adverse cardiovascular events. Methods Human cardiomyocytes co-cultured with human peripheral blood lymphocytes (hPBMCs) were exposed to monotherapy and combinatorial ICIs (PD-L1 and CTLA-4 or PD-1 and LAG-3 blocking agents, at 100 nM) for 48 h. After treatments, cardiac cell lysis and secretion of biomarkers of cardiotoxicity (H-FABP, troponin-T, BNP, NT-Pro-BNP), NLRP3-inflammasome and Interleukin 1 and 6 were determined through colorimetric and enzymatic assays. Mitochondrial functions were studied in cardiomyocyte cell lysates through quantification of intracellular Ca++, ATP content and NADH:ubiquinone oxidoreductase core subunit S1 (Ndufs1) levels. Histone deacetylases type 4 (HDAC-4) protein levels were also determined in cardiomyocyte cell lysates to study potential epigenetic changes induced by immunotherapy regimens. Results Both combinations of immune checkpoint inhibitors exert more potent cardiotoxic side effects compared to monotherapies against human cardiac cells co-cultured with human lymphocytes. LDH release from cardiac cells was 43% higher in PD-L1/CTLA-4 blocking agents, and 35.7% higher in PD-1/LAG-3 blocking agents compared to monotherapies. HDAC4 and intracellular Ca++ levels were increased, instead ATP content and Ndufs1 were reduced in myocardial cell lysates (p < 0.001 vs. untreated cells). Troponin-T, BNP, NT-Pro-BNP and H-FABP, were also strongly increased in combination therapy compared to monotherapy regimen. NLRP3 expression, IL-6 and IL-1β levels were also increased by PDL-1/CTLA-4 and PD-1/LAG-3 combined blocking agents compared to untreated cells and monotherapies. Conclusions Data of the present study, although in vitro, indicate that combinatorial immune checkpoint blockade, induce a pro- inflammatory phenotype, thus indicating that these therapies should be closely monitored by the multidisciplinary team consisting of oncologists, cardiologists and immunologists.
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Affiliation(s)
- V. Quagliariello
- Division of Cardiology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Naples, Italy
| | - M. Passariello
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Naples, Italy
| | - I. Bisceglia
- Servizi Cardiologici Integrati, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - A. Paccone
- Division of Cardiology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Naples, Italy
| | - A. Inno
- Medical Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Sacro Cuore Don Calabria, Negrar, Italy
| | - C. Maurea
- Medical Oncology, Ospedale del Mare, Naples, Italy
| | - R. Rapuano Lembo
- Department of Molecular Medicine, Ceinge-Biotecnologie Avanzate s.c.a.r.l., Naples, Italy
| | - L. Manna
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Naples, Italy
| | - M. Iovine
- Division of Cardiology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Naples, Italy
| | - M. L. Canale
- U.O.C. Cardiologia, Ospedale Versilia, Lido di Camaiore (LU), Camaiore, Italy
| | - M. Scherillo
- Cardiologia Interventistica e UTIC, A.O. San Pio, Presidio Ospedaliero Gaetano Rummo, Benevento, Italy
| | - P. A. Ascierto
- Melanoma Cancer Immunotherapy and Innovative Therapy Unit, Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Naples, Italy
| | - D. Gabrielli
- U.O.C. Cardiologia, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Roma – Fondazione per il Tuo Cuore – Heart Care Foundation, Firenze, Italy
| | - C. De Lorenzo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Naples, Italy
- Department of Molecular Medicine, Ceinge-Biotecnologie Avanzate s.c.a.r.l., Naples, Italy
| | - N. Maurea
- Division of Cardiology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Naples, Italy
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Miao YD, Quan WX, Tang XL, Shi WW, Li Q, Li RJ, Wang JT, Gan J, Dong X, Hao L, Luan WY, Zhang F. Uncovering the flip side of immune checkpoint inhibitors: a comprehensive review of immune-related adverse events and predictive biomarkers. Int J Biol Sci 2024; 20:621-642. [PMID: 38169638 PMCID: PMC10758091 DOI: 10.7150/ijbs.89376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) have generated considerable excitement as a novel class of immunotherapeutic agents due to their remarkable efficacy in treating various types of cancer. However, the widespread use of ICIs has brought about a number of safety concerns, especially the development of immune-related adverse events (irAEs). These serious complications could result in treatment discontinuation and even life-threatening consequences, making it critical to identify high-risk groups and predictive markers of irAEs before initiating therapy. To this end, the current article examines several potential predictive markers of irAEs in important organs affected by ICIs. While retrospective studies have yielded some promising results, limitations such as small sample sizes, variable patient populations, and specific cancer types and ICIs studied make it difficult to generalize the findings. Therefore, prospective cohort studies and real-world investigations are needed to validate the potential of different biomarkers in predicting irAEs risk. Overall, identifying predictive markers of irAEs is a crucial step towards improving patient safety and enhancing the management of irAEs. With ongoing research efforts, it is hoped that more accurate and reliable biomarkers will be identified and incorporated into clinical practice to guide treatment decisions and prevent the development of irAEs in susceptible patients.
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Affiliation(s)
- Yan-Dong Miao
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Wu-Xia Quan
- Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Xiao-Long Tang
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, China
| | - Wei-Wei Shi
- Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Qing Li
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Rui Jian Li
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Jiang-Tao Wang
- Department of Thyroid and Breast Surgery, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Jian Gan
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Xin Dong
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Liang Hao
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Wen-Yu Luan
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Fang Zhang
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
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5
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Xu L, Xu M, Sun W, Zhang W, Song Z. Clinical characteristics and prognostic impact of immune checkpoint inhibitor-associated myocarditis in advanced non-small cell lung cancer. Invest New Drugs 2023; 41:816-824. [PMID: 37902905 DOI: 10.1007/s10637-023-01400-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/04/2023] [Indexed: 11/01/2023]
Abstract
Myocarditis is a rare immune-related adverse events (irAEs) with high mortality rates, with few reports on its clinical characteristics and prognostic impact. This study designed to explore the associations between cardiac parameters and outcomes of myocarditis in advanced non-small cell lung cancer (NSCLC) who treated with immune checkpoint inhibitor (ICI). Fourteen patients diagnosed with ICI-associated myocarditis by clinicians were admitted to the study analysis. By Cox univariate and multivariate survival analyses, potential risk factors for the development of severe myocarditis were identified. Survival analysis was also performed to explore the prognosis of patients with myocarditis. Among patients with myocarditis, higher B-type natriuretic peptide (BNP) levels (P = 0.04) and conduction block (P = 0.03) were associated with progression to severe myocarditis. In addition, high lactate dehydrogenase (LHD) levels (P = .04) and myocarditis onset within 2 months (P = 0.02) were prognostic factors of severe myocarditis. The median progression-free survival (PFS) time and median overall survival (OS) time for all patients were 5.9 months and 18.5 months, respectively. However, there were no statistical differences between mild and severe cohorts in terms of PFS and OS (PFS: 4.5 vs. 8.5 months, P = 0.17; OS: 21.3 vs. 18.5months, P = 0.36). And we found that the earlier occurrence of myocarditis, worse PFS prognosis (4.5 months vs. 10.5 months, P = 0.008), while no difference in OS (18.5 months vs. 21.3 months, P = 0.35). Compared to mild myocarditis, severe myocarditis presented with higher BNP levels and cardiac conduction abnormalities. In addition, patients with mild and early myocarditis tended to have better survival rates.
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Affiliation(s)
- Lan Xu
- The third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Manyi Xu
- The second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Wei Sun
- Wenzhou Medical University, Wenzhou, China
| | - Weiping Zhang
- The third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhengbo Song
- Department of Clinical Trial, The Chinese Academy of Sciences University Cancer Hospital (Zhejiang Cancer Hospital), Hangzhou Institute of Medicine (HIM), No.1 East Banshan Road, Gongshu District, Hangzhou, Zhejiang, 310022, China.
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Paluri RK, Pulipati Y, Regalla DKR. Immune Checkpoint Inhibitors and Their Cardiovascular Adverse Effects. Oncol Rev 2023; 17:11456. [PMID: 38045806 PMCID: PMC10691592 DOI: 10.3389/or.2023.11456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 10/25/2023] [Indexed: 12/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have reshaped and have become a well-established treatment modality for multiple advanced-stage malignancies. ICIs block the immune system regulatory checkpoints, namely CTLA-4 and PD-1/PDL1, which provokes excess immune response against self-antigens. Immune modulation with ICIs can result in diverse immune-related adverse events targeting organ systems. Several cases of ICI-related cardiotoxicity were reported, while the actual incidence was likely underestimated due to heterogeneous clinical presentation. These include, but are not limited to, myocarditis, pericarditis, atherosclerosis, and arrhythmia. EKG, Troponin, Echocardiogram (TTE), and Cardiac MRI (CMRI) are indispensable diagnostic tools to aid in the management of cardiac adverse effects. Herein, we review the ICI-mediated cardiovascular adverse events, diagnosis, treatment strategies, and reintroduction of ICIs post-cardiotoxicity.
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Affiliation(s)
- Ravi Kumar Paluri
- Department of Hematology-Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States
| | - Yochitha Pulipati
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA, United States
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Abulnaja R. Stage 4 Non-small Cell Lung Cancer With Human Epidermal Growth Factor Receptor 2 Alterations and Myocarditis Induced by Immune Checkpoint Inhibitors: A Case Report. Cureus 2023; 15:e48859. [PMID: 38106717 PMCID: PMC10723805 DOI: 10.7759/cureus.48859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2023] [Indexed: 12/19/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)-induced myocarditis is one of the most serious and potentially fatal toxicities of immunotherapy. Most of the guidelines for managing this toxicity are based on expert opinions. Human epidermal growth factor receptor 2 (HER2) alterations in non-small cell lung cancer (NSCLC) could be found using next-generation sequencing (NGS) on tissue and liquid biopsies. There is an approved first-line targeted therapy for HER2-positive breast and gastroesophageal cancers. Until now, no first-line targeted therapy for NSCLC with HER2 alterations has been approved. This case report presents a patient with metastatic HER2 NSCLC with a high PD-L1 level. She was started on first-line single-agent immunotherapy pembrolizumab. She tolerated the first two cycles well. Before the third cycle, she had palpitations and was tachycardiac. Furthermore, investigations found raised troponin levels. She was diagnosed with ICI-induced myocarditis. After being admitted to the cardiac care unit (CCU) and beginning pulse steroid treatment, she responded well with decreasing troponin levels.
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Affiliation(s)
- Rakan Abulnaja
- Internal Medicine, Faculty of Medicine King Abdulaziz University Hospital, Jeddah, SAU
- Oncology, King Abdulaziz University Hospital, Jeddah, SAU
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8
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Vasbinder A, Ismail A, Salem JE, Hayek SS. Role of Biomarkers in the Management of Immune-Checkpoint Inhibitor-Related Myocarditis. Curr Cardiol Rep 2023; 25:959-967. [PMID: 37436648 DOI: 10.1007/s11886-023-01915-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI)-related myocarditis poses a major clinical challenge given its non-specific presentation, rapid progression, and high mortality rate. Here, we review the role of blood-based biomarkers in the clinical management of patients with ICI-related myocarditis. RECENT FINDINGS Myocardial injury, its unique pattern, and the co-occurrence with myositis are defining features of ICI-related myocarditis. Non-cardiac biomarkers, specifically creatinine phosphokinase, precedes the symptomatic presentation and is highly sensitive for diagnosing ICI-related myocarditis, making them useful screening biomarkers. Combined elevations in cardiac troponins and non-cardiac biomarkers improve the confidence of an ICI myocarditis diagnosis. High troponin and creatinine phosphokinase levels are strongly associated with severe outcomes. We propose biomarker-based algorithms for the monitoring and diagnosis of ICI-related myocarditis. Biomarkers, such as cardiac troponins and creatine phosphokinase, can be used in combination in the monitoring, diagnosis, and prognostication of patients with ICI-related myocarditis.
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Affiliation(s)
- Alexi Vasbinder
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA
| | - Anis Ismail
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA
| | - Joe-Elie Salem
- Department of Pharmacology and Clinical Investigation Centre, Pitié-Salpetriere Hospital, Sorbonne Universite, Paris, France
| | - Salim S Hayek
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA.
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9
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Battisha A, Sawalha K, Obeidat Y, Patel B. Role of Cardiac Biomarkers in Monitoring Cardiotoxicity in Chemotherapy Patients. Crit Pathw Cardiol 2023; 22:83-87. [PMID: 37607037 DOI: 10.1097/hpc.0000000000000314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
PURPOSE This review aims to highlight the different types of chemotherapy-induced cardiotoxicity and will discuss the evidence base behind the use of different cardiac biomarkers to predict cardiovascular complications. Additionally, we will review the use of cardiac biomarkers to monitor cardiac outcomes and the role of cardioprotective medications in reducing cardiovascular side effects. RECENT FINDINGS Chemotherapy has been linked to an increased risk of cardiotoxicity and heart failure. Currently, patients receiving chemotherapy undergo echocardiogram before starting chemotherapy and every 6 months to monitor for any decline in cardiac function. We reviewed the current evidence and practice guidelines of monitoring chemotherapy cardiotoxicity. SUMMARY Cardio-oncology is a rapidly evolving subspecialty in cardiology, especially with the advent of new chemotherapeutic agents, which have cardiovascular side effects. Early detection of these effects is crucial to prevent life-threatening and irreversible cardiovascular outcomes. Monitoring troponin, pro-brain natriuretic peptide, and other cardiac biomarkers during chemotherapy will help to early detect cardiotoxicity.
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Affiliation(s)
- Ayman Battisha
- From the Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Khalid Sawalha
- From the Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Yasin Obeidat
- From the Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Brijesh Patel
- Department of Cardiology, Heart and Vascular Institute, West Virginia University, Morgantown, WV
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10
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Inno A, Tarantini L, Parrini I, Spallarossa P, Maurea N, Bisceglia I, Silvestris N, Russo A, Gori S. Cardiovascular Effects of Immune Checkpoint Inhibitors: More Than Just Myocarditis. Curr Oncol Rep 2023; 25:743-751. [PMID: 37017825 DOI: 10.1007/s11912-023-01411-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/06/2023]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors have reshaped the treatment of cancer, but they are characterized by peculiar toxicity consisting of immune-related adverse events that may potentially affect any organ or system. In this review, we summarize data on clinical presentation, diagnosis, pathogenesis, and management of the main immune-related cardiovascular toxicities of immune checkpoint inhibitors. RECENT FINDINGS The most relevant immune-related cardiovascular toxicity is myocarditis, but other non-negligible reported events include non-inflammatory heart failure, conduction abnormalities, pericardial disease, and vasculitis. More recently, growing evidence suggests a role for immune checkpoint inhibitors in accelerating atherosclerosis and promoting plaque inflammation, thus leading to myocardial infarction. Immune checkpoint inhibitors are associated with several forms of cardiovascular toxicity; thus, an accurate cardiovascular baseline evaluation and periodical monitoring are required. Furthermore, the optimization of cardiovascular risk factors before, during, and after treatment may contribute to mitigating both short-term and long-term cardiovascular toxicity of these drugs.
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Affiliation(s)
- Alessandro Inno
- Oncologia Medica, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A Sempreboni 5, 37024, Negrar Di Valpolicella, VR, Italy.
| | - Luigi Tarantini
- Cardiologia Ospedaliera, AUSL - IRCCS in Tecnologie Avanzate E Modelli Assistenziali in Oncologia, Reggio Emilia, Italy
| | - Iris Parrini
- Dipartimento Di Cardiologia, Ospedale Mauriziano, Turin, Italy
| | - Paolo Spallarossa
- Clinica Di Malattie Dell'Apparato Cardiovascolare, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Nicola Maurea
- Struttura Complessa Cardiologia, Istituto Nazionale Tumori Di Napoli IRCCS Fondazione G. Pascale, Naples, Italy
| | - Irma Bisceglia
- Servizi Cardiologici Integrati, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Nicola Silvestris
- Oncologia Medica, Dipartimento Di Patologia Umana "G. Barresi", Università Di Messina, Messina, Italy
| | - Antonio Russo
- Dipartimento Di Discipline Chirurgiche, Oncologiche E Stomatologiche, Università Di Palermo, Palermo, Italy
| | - Stefania Gori
- Oncologia Medica, IRCCS Ospedale Sacro Cuore Don Calabria, Via Don A Sempreboni 5, 37024, Negrar Di Valpolicella, VR, Italy
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11
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Dehghani T, Shahrjerdi A, Kahrizi MS, Soleimani E, Ravandeh S, Merza MS, Rahnama N, Ebrahimzadeh F, Bakhshesh M. Targeting programmed cell death protein 1 (PD-1) for treatment of non-small-cell lung carcinoma (NSCLC); the recent advances. Pathol Res Pract 2023; 246:154470. [PMID: 37150133 DOI: 10.1016/j.prp.2023.154470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/09/2023]
Abstract
The immune system uses various immune checkpoint axes to adjust responses, support homeostasis, and deter self-reactivity and autoimmunity. Nevertheless, non-small-cell lung carcinoma (NSCLC) can use protective mechanisms to facilitate immune evasion, which leads to potentiated cancer survival and proliferation. In this light, many blocking anti-bodies have been developed to negatively regulate checkpoint molecules, in particular, programmed cell death protein 1 (PD-1) / PD-ligand 1 (L1), and bypass these immune suppressive mechanisms. Meanwhile, anti-PD-1 anti-bodies such as nivolumab, pembrolizumab, cemiplimab, and sintilimab have shown excellent competence in successfully inspiring immune responses versus NSCLC. Accordingly, the United States Food and Drug Administration (FDA) has recently approved nivolumab (alone or in combination with ipilimumab) and pembrolizumab (alone or in combination with chemotherapy) as first-line treatment for advanced NSCLC patients. However, PD-1 blockade monotherapy remains inefficient in more than 60% of NSCLC patients, and many patients don't respond or acquire resistance to this modality. Also, toxicities related to anti-PD-1 anti-body have been progressively identified in clinical trials and oncology practice. Herein, we will outline the clinical benefits of PD-1 blockade therapy alone or in combination with other treatments (e.g., chemotherapy, radiotherapy, anti-angiogenic therapy) in NSCLC patients. Moreover, we will take a glimpse into the recently identified predictive biomarkers to determine patients most likely to suffer serious adverse events to decrease untoward toxicity risk and diminish treatment costs.
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Affiliation(s)
- Tannaz Dehghani
- Department of Internal Medicine, Lorestan University of Medical Sciences, Lorestan, Iran
| | - Alireza Shahrjerdi
- National Institute for Genetic Engineering and Biotechnology (NIGEB), P.O. Box: 14965/161, Tehran, Iran
| | | | - Elnaz Soleimani
- Departmant of Genetic, Babol University of Medical Science, Babol, Iran
| | | | - Muna S Merza
- Prosthetic Dental Techniques Department, Al-Mustaqbal university College, Babylon 51001, Iraq
| | - Negin Rahnama
- Department of Internal Medicine and Health Services, Semnan University of Medical Sciences, Semnan, Iran
| | - Farnoosh Ebrahimzadeh
- Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Morteza Bakhshesh
- Molecular and Medicine Research Center, Khomein University of Medical Sciences, Khomein, Iran.
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12
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Hu Y, Liu C, Jin S, Yi Z, Wang C, Pan X, Huang H. A case of subclinical immune checkpoint inhibitor-associated myocarditis in non-small cell lung cancer. BMC Pulm Med 2023; 23:119. [PMID: 37060029 PMCID: PMC10103507 DOI: 10.1186/s12890-023-02417-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/04/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have been widely used in the treatment of cancer. Moreover, immune-related adverse events (irAEs) have become a new clinical challenge. ICI-associated myocarditis is a rare but fatal condition among diverse organ injuries, and early recognition and effective interventions are critical for patients. CASE PRESENTATION In this report, we present the case of a healthy 60-year-old male who was diagnosed with lung squamous cell carcinomas following chemotherapy and received ICIs. The patient presented with asymptomatic cardiac biomarker elevation followed by immune-related myocarditis. Fortunately, the patient achieved a good clinical result after receiving high-dose steroids. The treatment with ICIs was discontinued because of recurrent increases in troponin T. CONCLUSION ICI-mediated associated myocarditis is an uncommon but potentially life-threatening adverse event. The current data suggest that clinicians need to be cautious about reinitiation in low-grade patients; however, further study of the diagnosis and treatment is necessary.
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Affiliation(s)
- Yue Hu
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China.
- Cancer Center, Zhejiang University, Hangzhou, 310058, Zhejiang, China.
| | - Cuixia Liu
- Department of Respiratory and Critical Care Medicine, Songyang people's Hospital of Zhejiang, Lishui, 323499, Zhejiang, China
| | - Shaojun Jin
- Department of emergency, Zhuji people's Hospital of Zhejiang, Zhuji, 311800, Zhejiang, China
| | - Zihan Yi
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China
- Cancer Center, Zhejiang University, Hangzhou, 310058, Zhejiang, China
| | - Chao Wang
- Department of Radiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China
| | - Xiaohong Pan
- Department of Cardiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China
| | - Huaqiong Huang
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China.
- Cancer Center, Zhejiang University, Hangzhou, 310058, Zhejiang, China.
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13
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Boutros A, Bottini A, Rossi G, Tanda ET, Spagnolo F, Barletta G, Croce E, Fava P, Parisi A, De Rosa F, Palla M, Marconcini R, Ferrari M, Grandis M, Spallarossa P, Sarocchi M, Arboscello E, Del Mastro L, Lambertini M, Pronzato P, Genova C. Neuromuscular and cardiac adverse events associated with immune checkpoint inhibitors: pooled analysis of individual cases from multiple institutions and literature. ESMO Open 2023; 8:100791. [PMID: 36791639 PMCID: PMC9958259 DOI: 10.1016/j.esmoop.2023.100791] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have revolutionized the management of multiple tumors, due to improved efficacy, quality of life, and safety. While most immune-related adverse events (irAEs) are mild and easily managed, in rare cases such events may be life-threatening, especially those affecting the neuromuscular and cardiac system. The management of neuromuscular/cardiac irAEs is not clear due to the lack of consistent data. Therefore, we carried out a pooled analysis of collected cases from selected Italian centers and individual data from published case reports and case series, in order to improve our understanding of these irAEs. PATIENTS AND METHODS We collected retrospective data from patients treated in six Italian centers with ICIs (programmed cell death protein 1 or programmed death-ligand 1 and/or cytotoxic T-lymphocyte antigen 4 inhibitor) for any solid tumor who experienced neuromuscular and/or cardiovascular toxicity. Then, we carried out a search of case reports and series of neuromuscular/cardiac irAEs from ICIs with any solid tumor. RESULTS This analysis includes cases from Italian institutions (n = 18) and the case reports identified in our systematic literature search (n = 120), for a total of 138 patients. Among these patients, 50 (36.2%) had complete resolution of their neuromuscular/cardiac irAEs, in 21 (15.2%) cases there was a clinical improvement with mild sequelae, and 53 (38.4%) patients died as a result of the irAEs. Factors significantly associated with worse outcomes were early irAE onset, within the first two cycles of ICI (Fisher P < 0.0001), clinical manifestation of both myositis and myocarditis when compared with patients who developed only myositis or myocarditis (chi-square P = 0.0045), and the development of arrhythmia (Fisher P = 0.0070). CONCLUSIONS To the best of our knowledge, this is the largest collection of individual cases of immune-related myocarditis/myositis. Early irAE onset, concurrent development of myositis and myocarditis, as well as occurrence of arrhythmias are associated with worse outcomes and should encourage an aggressive immunomodulatory treatment.
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Affiliation(s)
- A Boutros
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy.
| | - A Bottini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy
| | - G Rossi
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - E T Tanda
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - F Spagnolo
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), Plastic Surgery Division, University of Genova, Genoa, Italy
| | - G Barletta
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - E Croce
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Fava
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Torino, Italy
| | - A Parisi
- Department of Life, Health & Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - F De Rosa
- IRCCS Istituto Romagnolo per lo Studio dei Tumori 'Dino Amadori', Meldola (FC), Italy
| | - M Palla
- Department of Skin Cancers, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - R Marconcini
- Azienda Ospedaliero Universitaria Pisana, Medical Oncology Unit, Pisa, Italy
| | - M Ferrari
- Azienda Ospedaliero Universitaria Pisana, Medical Oncology Unit, Pisa, Italy
| | - M Grandis
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Spallarossa
- Cardiovascular Disease Unit, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - M Sarocchi
- Cardiovascular Disease Unit, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - E Arboscello
- Emergency Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - L Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy; Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - M Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy; Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Pronzato
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - C Genova
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy; Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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14
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Ulndreaj A, Brinc D, Altan M, Pons-Belda OD, Fernandez-Uriarte A, Mu-Mosley H, Fattah F, von Itzstein MS, Soosaipillai A, Kulasingam V, Palaskas NL, Gerber DE, Diamandis EP, Heymach JV, Prassas I. Quantitation of cardiac troponin I in cancer patients treated with immune checkpoint inhibitors: a case-control study. Clin Chem Lab Med 2023; 61:154-161. [PMID: 36287134 DOI: 10.1515/cclm-2022-0471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/21/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Immune checkpoint inhibitors (ICIs) cause a variety of toxicities, including immune-related adverse events (irAEs), but there are no biomarkers to predict their development. Guidelines recommend measuring circulating cardiac troponin I (cTnI) during ICI therapy to detect related cardiotoxicities. Moreover, elevated cTnI has also been associated with worse outcomes in non-cardiac patients, including cancer. Thus here, we investigated whether cTnI levels were higher in patients with irAEs. METHODS The study consisted of three groups; 21 cancer patients undergoing ICI immunotherapies who presented with irAEs, four patients without irAEs, and 20 healthy controls. Patient samples were assessed at baseline (n=25), during ICI treatment (n=25, median=6 weeks of treatment) and at toxicity (n=6, median=13 weeks of treatment). In addition to blood high sensitivity cardiac troponin I (hs-cTnI), anti-thyroglobulin (TG) and anti-thyroid peroxidase (TPO) antibodies were also quantitated to detect thyroid dysfunction, constituting the second leading toxicity (23.8%) after pneumonitis (28.6%). RESULTS Four patients with irAEs (n=4/21; 19%) and one without irAEs (n=1/4; 25%) showed higher hs-cTnI levels at any time-point; the remaining had physiological levels. None of these patients developed cardiotoxicity. Concurrent elevated levels of anti-thyroid antibodies and hs-cTnI were detected in one patient with thyroid dysfunction (n=1/5, 20%). However, these antibodies were also elevated in three patients (n=3/16, 19%) with non-thyroid irAEs and in up to 40% of healthy controls. CONCLUSIONS hs-cTnI was not elevated in patients with irAEs, but larger studies are needed to confirm these observations.
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Affiliation(s)
- Antigona Ulndreaj
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Davor Brinc
- Department of Clinical Biochemistry, University Health Network, Toronto, ON, Canada
| | - Mehmet Altan
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Oscar D Pons-Belda
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Hong Mu-Mosley
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Farjana Fattah
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mitchell S von Itzstein
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Internal Medicine (Division of Hematology-Oncology), University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Antoninus Soosaipillai
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Vathany Kulasingam
- Department of Clinical Biochemistry, University Health Network, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Nicolas L Palaskas
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David E Gerber
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Internal Medicine (Division of Hematology-Oncology), University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Eleftherios P Diamandis
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - John V Heymach
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ioannis Prassas
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
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15
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Malaty MM, Amarasekera AT, Li C, Scherrer-Crosbie M, Tan TC. Incidence of immune checkpoint inhibitor mediated cardiovascular toxicity: A systematic review and meta-analysis. Eur J Clin Invest 2022; 52:e13831. [PMID: 35788986 DOI: 10.1111/eci.13831] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/24/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) are a novel class of anti-cancer therapy becoming increasingly associated with fatal cardiovascular toxicities (CVTs). The aim is to determine the incidence of CVTs in cohorts treated with ICIs as sole anti-cancer therapy. METHODS A systematic literature search of scientific and medical databases was performed using PRISMA principles to identify relevant cohorts (PROSPERO registration CRD42021272470). Data for specific CVTs (pericardial disease, myocarditis, heart failure, arrhythmia, myocardial infarction/ischaemia and angina), CVT-related death and CV risk factors were extracted. Presence of CVTs in ICI-monotherapy versus combination-ICI therapy, and programmed death 1/programmed death ligand 1- (PD1/PDL1-) versus cytotoxic T-lymphocyte-associated protein 4- (CTLA4-) inhibitor groups were dichotomised and meta-analysed using random-effect models. RESULTS Forty-eight studies (11,207 patients) were identified, from which 146 CVTs were observed (incidence 1.30%). ICI-monotherapy led to more CVTs than combination therapy (119/9009; 1.32% vs. 18/2086; 0.86%). Across monotherapies, PD1/PDL1-inhibitors had lower incidence of CVTs compared to CTLA4-inhibitors (62/6950; 0.89% vs. 57/2059; 2.77%). Based on eight studies that were meta-analysed, no significant difference was observed comparing monotherapy versus combination-ICI therapy (RR-0.69, 95% CI -1.47 to 0.09) for all CVTs, or PD1/PDL1- to CTLA4-inhibitors (RR-0.27, 95% CI -2.06 to 1.53), for all CVTs including CVT-death. CV risk factors could not be attributed to an ICI group as data was population based rather than individual based. CONCLUSION ICI-mediated CVTs are rare and potentially fatal. The role of CV risk factors in their development remains unclear.
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Affiliation(s)
- Michael M Malaty
- Department of Cardiology, Blacktown Hospital, Western Sydney Local Health District, Sydney, Australia
| | - Anjalee Thanuja Amarasekera
- School of Medicine, Western Sydney University, Sydney, Australia.,Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, Sydney, Australia.,Westmead Applied Research Centre (WARC), Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Cindy Li
- Department of Cardiology, Blacktown Hospital, Western Sydney Local Health District, Sydney, Australia
| | - Marielle Scherrer-Crosbie
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Western Sydney Local Health District, Sydney, Australia.,School of Medicine, Western Sydney University, Sydney, Australia.,Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, Sydney, Australia
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16
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Nishikawa T, Inoue T, Otsuka T, Kuno I, Kukita Y, Nakamura H, Ikeda Y, Yasui T, Shioyama W, Oka T, Honma K, Hatakeyama K, Miyata H, Isei T, Ishihara R, Kumagai T, Nishimura K, Fujita M. Prevalence and characteristics of immune checkpoint inhibitor-related myocardial damage: A prospective observational study. PLoS One 2022; 17:e0275865. [PMCID: PMC9665386 DOI: 10.1371/journal.pone.0275865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022] Open
Abstract
An increasing number of patients with cancer are being treated with immune checkpoint inhibitors. Consequently, the incidence of immune checkpoint inhibitor-related myocarditis has been increasing. Nonetheless, the diagnostic criteria for the immune checkpoint inhibitor-related myocarditis have not been sufficiently established. Therefore, the real-world incidence or prevalence of immune checkpoint inhibitor-related myocardial damage remains unknown. This was a single-center cohort study that included 100 patients admitted for immune checkpoint inhibitor therapy for any type of cancer. The patients underwent monthly measurement of cardiac troponin I and N-terminal pro-brain natriuretic peptide levels with electrocardiography. Additionally, echocardiography was performed every 3 months. Our protocol was continued until 6 months after the initiation of immune checkpoint inhibitors. We defined immune checkpoint inhibitor-related myocardial damage as an increase in cardiac troponin I levels by >0.026 ng/mL and/or a decrease in the left ventricular ejection fraction by >10% to <53% on echocardiography. The mean patient age was 64 years; 71% were men. The most commonly used immune checkpoint inhibitor was nivolumab (47%), followed by pembrolizumab (29%). Overall, 5% of patients received combination therapy. Among 100 patients, 10 (10%) were diagnosed with immune checkpoint inhibitor-related myocardial damage. Among them, five patients underwent endomyocardial biopsy. Of these patients, four were histopathologically observed to have lymphocyte infiltration in their myocardium. In conclusion, serial cardiac troponin I measurement during immune checkpoint inhibitor treatment could help detect early-phase myocardial damage. The prevalence of myocardial damage was much higher than previously expected.
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Affiliation(s)
- Tatsuya Nishikawa
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
- * E-mail: (TN); (MF)
| | - Takako Inoue
- Department of Thoracic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Tomoyuki Otsuka
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ikumi Kuno
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoji Kukita
- Laboratory of Genomic Pathology, Osaka International Cancer Institute, Osaka, Japan
| | - Harumi Nakamura
- Laboratory of Genomic Pathology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshihiko Ikeda
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Taku Yasui
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Wataru Shioyama
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Toru Oka
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Keiichirou Honma
- Department of Pathology, Osaka International Cancer Institute, Osaka, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Miyata
- Department of Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Taiki Isei
- Department of Dermatological Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Toru Kumagai
- Department of Thoracic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuo Nishimura
- Department of Urology, Osaka International Cancer Institute, Osaka, Japan
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
- * E-mail: (TN); (MF)
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17
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Lei Y, Zheng X, Huang Q, Li X, Qiu M, Liu M. Intrinsic Differences in Immune Checkpoint Inhibitor-Induced Myocarditis: A Retrospective Analysis of Real World Data. Front Pharmacol 2022; 13:914928. [PMID: 35865949 PMCID: PMC9294234 DOI: 10.3389/fphar.2022.914928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/06/2022] [Indexed: 12/01/2022] Open
Abstract
Immune-related myocarditis is a severe and even life-threatening immune-related adverse event (irAE) which may also be underestimated due to the challenge in diagnosis. The inherent difference between individuals with immune-associated myocarditis has received little attention. Our study aimed to identify which baseline characteristics could contribute to distinguishing mild from severe ICI myocarditis. A retrospective analysis was conducted between March 2019 and June 2020 in West China Hospital, and 18 patients with immune-related myocarditis were studied. Patients were classified as having mild (n = 12) or severe myocarditis (n = 6), according to the clinical manifestations and hemodynamic complications. Factors associated with severe myocarditis were identified by comparing covariates derived from medical records in various groups. In this retrospective analysis, the median age of the 18 patients was 60 years old. Most myocarditis cases occur early and approximately after the first or second ICI infusion. The severity of myocarditis may be correlated with lactate dehydrogenase (LDH) (p = 0.04) and troponin levels (p = 0.0057). The relationship between troponin and myocarditis was further confirmed in another cohort, which included 30 patients. In addition, patients are more likely to develop multi-irAEs, and myositis was the most common second irAE. Those who experience multi-irAEs usually had significantly higher LDH (p = 0.02) and myoglobin levels (p = 0.02) than those who did not experience them. All patients were treated with steroids timely, and the mortality rate was 5.6% in our study. In this study, we explored risk factors for severe myocarditis and emphasized the importance of a multidisciplinary team in assisting diagnosis and treatment options. It is critical to initiate corticosteroid therapy, regardless of the severity of the myocarditis.
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18
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Tsuruda T, Sato Y, Tomita M, Tanaka H, Hatakeyama K, Otsu M, Kawano A, Nagatomo K, Yoshikawa N, Ikeda R, Asada Y, Kaikita K. Aberrant Expression of Cardiac Troponin-T in Lung Cancer Tissues in Association With Pathological Severity. Front Cardiovasc Med 2022; 9:833649. [PMID: 35479276 PMCID: PMC9037982 DOI: 10.3389/fcvm.2022.833649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cardiac troponin-T (TNNT2) is exclusively present in cardiac muscle. Measurement of TNNT2 is used for diagnosing acute coronary syndrome. However, its expression may not be limited in myocardium. This study aimed at evaluating the expression of TNNT2 in neoplastic tissues. Methods and Results We used paraffin-embedded blocks of 68 patients with lung cancer (age, 68 ± 11 years old; early-stage, 33; advance-stage, 35) at Miyazaki University Hospital, Japan between January 1, 2017, and March 31, 2019. We stained the slide sections with primary monoclonal antibody against TNNT2 protein, and assessed the frequency of positive staining, and its association with pathological severity. In addition, we examined whether TNNT2 gene is detected in lung cancer tissues of four patients using reverse transcription-polymerase chain reaction. Immunoreactivity for TNNT2 protein was present in the cytoplasm and nucleus of lung cancer cells. The frequency was 37% (25 of 68) in all patients and was irrespective of histologic type (six of 13, squamous cell carcinoma; 18 of 50, adenocarcinoma; 0 of 4, neuroendocrine cell carcinoma; 1 of 1, large cell carcinoma). The prevalence increased with pathological staging [9% (3 of 33) at early-stage (Stage 0–I); 63% (22 of 35) at advance-stage (Stage II–IV and recurrence)]. In addition, frequency of positive staining for TNNT2 increased with pleural (χ2 = 5.877, P = 0.015) and vascular (χ2 = 2.449, P = 0.118) invasions but decreased with lymphatic invasion (χ2 = 3.288, P = 0.070) in specimens performed surgical resection. Furthermore, TNNT2 mRNA was detected in the resected squamous cell carcinoma and adenocarcinoma tissues. Conclusions Our data suggest the aberrant expression of TNNT2 in lung cancer and its prevalence increases with pathological severity.
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Affiliation(s)
- Toshihiro Tsuruda
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- *Correspondence: Toshihiro Tsuruda
| | - Yuichiro Sato
- Department of Diagnostic Pathology, Faculty of Medicine, Miyazaki University Hospital, Miyazaki, Japan
| | - Masaki Tomita
- Department of Thoracic and Breast Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Hiroyuki Tanaka
- Department of Pathology, Section of Oncopathology and Regenerative Biology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Misa Otsu
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Aya Kawano
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Keiko Nagatomo
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Naoki Yoshikawa
- Department of Pharmacy, Faculty of Medicine, Miyazaki University Hospital, Miyazaki, Japan
| | - Ryuji Ikeda
- Department of Pharmacy, Faculty of Medicine, Miyazaki University Hospital, Miyazaki, Japan
| | - Yujiro Asada
- Department of Pathology, Faculty of Medicine, Miyazaki University Hospital, Miyazaki, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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19
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Arcari L, Tini G, Camastra G, Ciolina F, De Santis D, Russo D, Caruso D, Danti M, Cacciotti L. Cardiac Magnetic Resonance Imaging in Immune Check-Point Inhibitor Myocarditis: A Systematic Review. J Imaging 2022; 8:jimaging8040099. [PMID: 35448226 PMCID: PMC9027245 DOI: 10.3390/jimaging8040099] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 12/02/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a family of anticancer drugs in which the immune response elicited against the tumor may involve other organs, including the heart. Cardiac magnetic resonance (CMR) imaging is increasingly used in the diagnostic work-up of myocardial inflammation; recently, several studies investigated the use of CMR in patients with ICI-myocarditis (ICI-M). The aim of the present systematic review is to summarize the available evidence on CMR findings in ICI-M. We searched electronic databases for relevant publications; after screening, six studies were selected, including 166 patients from five cohorts, and further 86 patients from a sub-analysis that were targeted for a tissue mapping assessment. CMR revealed mostly preserved left ventricular ejection fraction; edema prevalence ranged from 9% to 60%; late gadolinium enhancement (LGE) prevalence ranged from 23% to 83%. T1 and T2 mapping assessment were performed in 108 and 104 patients, respectively. When available, the comparison of CMR with endomyocardial biopsy revealed partial agreement between techniques and was higher for native T1 mapping amongst imaging biomarkers. The prognostic assessment was inconsistently assessed; CMR variables independently associated with the outcome included decreasing LVEF and increasing native T1. In conclusion, CMR findings in ICI-M include myocardial dysfunction, edema and fibrosis, though less evident than in more classic forms of myocarditis; native T1 mapping retained the higher concordance with EMB and significant prognostic value.
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Affiliation(s)
- Luca Arcari
- Cardiology Unit, Madre Giuseppina Vannini Hospital, 00177 Rome, Italy; (G.C.); (L.C.)
- Correspondence: ; Tel.: +39-0624291416
| | - Giacomo Tini
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza-University of Rome, 00100 Rome, Italy; (G.T.); (D.R.)
| | - Giovanni Camastra
- Cardiology Unit, Madre Giuseppina Vannini Hospital, 00177 Rome, Italy; (G.C.); (L.C.)
| | - Federica Ciolina
- Radiology Unit, Madre Giuseppina Vannini Hospital, 00177 Rome, Italy; (F.C.); (M.D.)
| | - Domenico De Santis
- Radiology Unit, Department of Medical Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza-University of Rome, 00100 Rome, Italy; (D.D.S.); (D.C.)
| | - Domitilla Russo
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza-University of Rome, 00100 Rome, Italy; (G.T.); (D.R.)
| | - Damiano Caruso
- Radiology Unit, Department of Medical Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza-University of Rome, 00100 Rome, Italy; (D.D.S.); (D.C.)
| | - Massimiliano Danti
- Radiology Unit, Madre Giuseppina Vannini Hospital, 00177 Rome, Italy; (F.C.); (M.D.)
| | - Luca Cacciotti
- Cardiology Unit, Madre Giuseppina Vannini Hospital, 00177 Rome, Italy; (G.C.); (L.C.)
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20
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Rubio-Infante N, Ramírez-Flores YA, Castillo EC, Lozano O, García-Rivas G, Torre-Amione G. A Systematic Review of the Mechanisms Involved in Immune Checkpoint Inhibitors Cardiotoxicity and Challenges to Improve Clinical Safety. Front Cell Dev Biol 2022; 10:851032. [PMID: 35433707 PMCID: PMC9006991 DOI: 10.3389/fcell.2022.851032] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/02/2022] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that block CTLA-4, PD-1, or PD-L1 and induce the activation of the immune system against cancer. Despite the efficacy of ICIs, which has improved the oncotherapy for patients with a variety of malignancies, several immune-related adverse events (irAEs) have been described, including those affecting the heart. Cardiac irAEs after ICI therapies, including myocarditis, can become life-threatening, and their pathogenic mechanisms remain unclear. Here, a systematic analysis was performed regarding the potential immune mechanisms underlying cardiac irAEs based on the immune adverse events induced by the ICIs: 1) recruitment of CD4+ and CD8+ T cells, 2) autoantibody-mediated cardiotoxicity, and 3) inflammatory cytokines. Furthermore, the impact of dual therapies in ICI-induced cardiac irAEs and the potential risk factors are reviewed. We propose that self-antigens released from cardiac tissues or cancer cells and the severity/advancement of cancer disease have an important role in ICI cardiotoxicity.
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Affiliation(s)
- Nestor Rubio-Infante
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
| | - Yoel Adbel Ramírez-Flores
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
| | - Elena Cristina Castillo
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
| | - Omar Lozano
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Investigación Biomédica, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
- Tecnologico de Monterrey, The Institute for Obesity Research, Monterrey, Mexico
| | - Gerardo García-Rivas
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Investigación Biomédica, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
- Tecnologico de Monterrey, The Institute for Obesity Research, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Medicina Funcional, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
- *Correspondence: Gerardo García-Rivas, ; Guillermo Torre-Amione,
| | - Guillermo Torre-Amione
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Investigación Biomédica, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
- Tecnologico de Monterrey, The Institute for Obesity Research, Monterrey, Mexico
- Tecnologico de Monterrey, Centro de Medicina Funcional, Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Mexico
- The Methodist Hospital, Cornell University, Houston, TX, United States
- *Correspondence: Gerardo García-Rivas, ; Guillermo Torre-Amione,
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21
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Isawa T, Toi Y, Sugawara S, Taguri M, Toyoda S. OUP accepted manuscript. Oncologist 2022; 27:e410-e419. [PMID: 35348766 PMCID: PMC9074992 DOI: 10.1093/oncolo/oyac056] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 02/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background Cardiovascular immune-related adverse events (CV–irAEs) associated with immune checkpoint inhibitors (ICIs) may have been underreported given that most previous reports were retrospective. We aimed to evaluate the incidence, clinical characteristics, and predictors of CV–irAEs and determine the feasibility of serial cardiac monitoring using a combination of B-type natriuretic peptide, cardiac troponin T, and electrocardiogram for the prediction of future symptomatic (grade ≥2) CV–irAEs. Materials and Methods This was a prospective observational study that included 129 consecutive patients with non–small-cell lung cancer who received ICI monotherapy at a single center. Serial cardiac monitoring was performed during ICI monotherapy. Results A total of 35 (27%) patients developed any grade ≥1 CV–irAEs with a median time of onset of 72 (interquartile range 44-216) days after ICI treatment initiation. Multivariate Fine–Gray regression analysis showed that prior acute coronary syndrome (adjusted hazard ratio [HR] 3.15 (95% [CI], 2.03-4.91), prior heart failure hospitalization (adjusted HR 1.65 [95% CI, 1.17-2.33]), and achievement of disease control (adjusted HR 1.91, [95% CI, 1.16-3.14]) were significantly associated with grade ≥1 CV–irAEs. Serial cardiac monitoring revealed that patients with preceding grade 1 CV–irAEs were associated with a significantly higher risk of onset of grade ≥2 CV–irAEs compared with those without preceding grade 1 CV–irAEs (HR: 6.17 [95% CI, 2.97-12.83]). Conclusion CV–irAEs were more common than previously recognized and have several predictors. Moreover, serial cardiac monitoring may be feasible for the prediction of future grade ≥2 CV–irAEs.
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Affiliation(s)
- Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
- Corresponding author: Tsuyoshi Isawa, MD, Department of Cardiology, Sendai Kousei Hospital, 4-15, Hirose-machi, Sendai, Miyagi 980-0873, Japan. Tel: 81 22 222 6181; Fax: 81 22 223 8422; e-mail:
| | - Yukihiro Toi
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Sendai, Japan
| | - Shunichi Sugawara
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Sendai, Japan
| | - Masataka Taguri
- Department of Data Science, Yokohama City University School of Data Science, Yokohama, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University, Mibu, Japan
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22
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Carbone F, Ministrini S, Bonaventura A, Vecchié A, Minetti S, Bardi N, Elia E, Ansaldo AM, Ferrara D, Rijavec E, Dal Bello MG, Biello F, Rossi G, Tagliamento M, Alama A, Coco S, Spallarossa P, Grossi F, Genova C, Montecucco F. Serum levels of VCAM-1 are associated with survival in patients treated with nivolumab for NSCLC. Eur J Clin Invest 2022; 52:e13668. [PMID: 34390488 PMCID: PMC9286788 DOI: 10.1111/eci.13668] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/01/2021] [Accepted: 08/08/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND High circulating levels of cellular adhesion molecules (CAMs) in non-small cell lung cancer (NSCLC) have been supposed to act as a negative prognostic factor. Here, we explored the predictive role of pre-treatment levels of CAMs in previously treated patients receiving nivolumab for NSCLC. MATERIALS AND METHODS Seventy one patients with advanced NSCLC, treated with nivolumab at the dose of 3 mg/kg every 14 days, were enrolled. Maximum follow-up time was 3 years. Serum levels of Vascular Cell Adhesion Molecule-1 (VCAM-1) and Intracellular Adhesion Molecule-1 (ICAM-1) were measured at baseline and before each nivolumab administration. Endpoints of the study were a composite outcome of survival ≥2 years or absence of disease progression at the end of the follow-up, and the overall survival. RESULTS Composite outcome and overall survival were positively associated with VCAM-1 baseline levels and with the reduction of VCAM-1 during the treatment. After adjustment for potential confounders, the change in VCAM-1 serum levels during the treatment was an independent predictor of overall survival. CONCLUSIONS High baseline serum levels of VCAM-1 are associated with a longer survival in patients treated with nivolumab as second line treatment for NSCLC. Surviving patients experience also a significant reduction in CAMs expression during the treatment. Hence, CAMs might be promising prognostic factors in patients with NSCLC underoing immunotherapy.
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Affiliation(s)
- Federico Carbone
- First Clinic of internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa - Italian Cardiovascular Network, Genoa, Italy
| | - Stefano Ministrini
- Center for Molecular Cardiology, Universität Zürich, Schlieren, Switzerland.,Internal Medicine, Angiology and Atherosclerosis, Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Aldo Bonaventura
- First Clinic of internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Alessandra Vecchié
- First Clinic of internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Silvia Minetti
- First Clinic of internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Nicholas Bardi
- First Clinic of internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Edoardo Elia
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Anna Maria Ansaldo
- First Clinic of internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Daniele Ferrara
- First Clinic of internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Erika Rijavec
- Medical Oncology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Federico Biello
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, Genoa, Italy
| | - Giovanni Rossi
- UOS Tumori Polmonari, IRCCS Ospedale Policlinico San Martino Genoa, Genoa, Italy
| | - Marco Tagliamento
- UOS Tumori Polmonari, IRCCS Ospedale Policlinico San Martino Genoa, Genoa, Italy.,Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, Genoa, Italy
| | - Angela Alama
- UOS Tumori Polmonari, IRCCS Ospedale Policlinico San Martino Genoa, Genoa, Italy
| | - Simona Coco
- UOS Tumori Polmonari, IRCCS Ospedale Policlinico San Martino Genoa, Genoa, Italy
| | - Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino Genoa, Genoa, Italy
| | - Francesco Grossi
- Medical Oncology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Genova
- UOS Tumori Polmonari, IRCCS Ospedale Policlinico San Martino Genoa, Genoa, Italy.,Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, Genoa, Italy
| | - Fabrizio Montecucco
- First Clinic of internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa - Italian Cardiovascular Network, Genoa, Italy
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23
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Role of Cardiac Biomarkers in Cancer Patients. Cancers (Basel) 2021; 13:cancers13215426. [PMID: 34771589 PMCID: PMC8582425 DOI: 10.3390/cancers13215426] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 02/02/2023] Open
Abstract
Simple Summary Cardiac biomarkers have proved increasingly useful in the various branches of cardiology, not sparing the field of cardio-oncology. With specific reference to the latter subject, they have been investigated as predictors and/or diagnostic and monitoring tools, as well as prognostic factors, with the purpose of allowing the early prevention of many cardiovascular complications related to the direct action of some cancer types or related to the toxicity of its treatments. However, despite this great potential and excellent cost-effectiveness, their usefulness in some areas still seems to be limited due to lack of sufficient specificity or sensitivity. In fact, in clinical practice, while their use is nowadays standard in some circumstances, evidence does not yet support their routine use in other cases. Abstract In patients with cancer—and especially some specific subtypes—the heart can be pathologically affected due to the direct action of the tumor or its secretion products or due to the toxicity of some oncological treatments. Cardiac biomarkers have been investigated as inexpensive and easily accessible tools for prediction, early diagnosis, monitoring, or prognosis of various forms of cancer-related cardiac diseases. However, their clinical usefulness was not always clearly demonstrated in every area of cardioncology. For the identification of anthracycline related cardiotoxicity in the very early stages troponins proved to be more efficient detectors than imaging methods. Nevertheless, the lack of a standardized dosage methodology and of cardiotoxicity specific thresholds, do not yet allow to outline the precise way to employ them in clinical routine and to incorporate them into appropriate diagnostic or managing algorithms. Cardiac biomarkers proved also effective in patients with primary cardiac amyloidosis, in which both troponins and natriuretic peptides were able to predict adverse outcome, and carcinoid heart disease, where a precise diagnostic cut-off for N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was identified to screen patients with valvular involvement. Likewise, NT-proBNP proved to be an excellent predictor of postoperative atrial fibrillation (POAF). On the contrary, evidence is still not sufficient to promote the routine use of cardiac biomarkers to early diagnose myocarditis due to immune check points inhibitors (ICIs), radiotherapy induced cardiotoxicity and cardiac complications related to androgenetic deprivation. In this review we present all the evidence gathered so far regarding the usefulness and limitations of these relatively inexpensive diagnostic tools in the field of cardio-oncology.
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24
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Cardiac Toxicity Associated with Immune Checkpoint Inhibitors: A Systematic Review. Cancers (Basel) 2021; 13:cancers13205218. [PMID: 34680365 PMCID: PMC8534225 DOI: 10.3390/cancers13205218] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/02/2021] [Accepted: 10/08/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary This review article addresses the toxic effects on the heart associated with the use of certain cancer-treating drugs known as immune checkpoint inhibitors. These drugs target specific proteins in the cell cycle that are abundantly expressed in cancerous cells; however, they inadvertently damage non-cancerous tissue. In the heart, this occurs in the form of dysfunction or death of smooth muscle cells, leading to consequences such as infection, heart rhythm changes, and hormonally dependent and independent ischemia. This review examines the average and median onset of these drug toxicities as well as antidotes. One key observation is that these side effects are positively skewed, meaning they occur early in cancer treatment. Abstract Immune checkpoint inhibitors are immune stimulatory drugs used to treat many types of cancer. These drugs are antibodies against inhibitory proteins, such as CTLA-4 and PD-1/PD-L1, that are expressed on immune cells. When bound, they allow for increased stimulation of T cells to fight tumor cells. However, immune checkpoint inhibitors have several immune-related adverse effects. Many cases have come to light recently of cardiotoxicity as a result of treatment with these drugs. Cardiotoxicity from immune checkpoint inhibitors is unique due to its rarity and high mortality rate. Patients with this toxicity may present with myocarditis, pericarditis, Takotsubo cardiomyopathy, conduction disorders, and others within just a few weeks of starting immune checkpoint inhibitors. We present here a review of the current research on immune checkpoint inhibitors, their associated cardiotoxicities, the timing of presentation of these conditions, lab tests and histology for each condition, and finally the treatment of patients with cardiotoxicity. We observe a positive skew in the onset of presentation, which is significant for the treating physician.
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25
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Delombaerde D, Vervloet D, Franssen C, Croes L, Gremonprez F, Prenen H, Peeters M, Vulsteke C. Clinical implications of isolated troponinemia following immune checkpoint inhibitor therapy. ESMO Open 2021; 6:100216. [PMID: 34271309 PMCID: PMC8287144 DOI: 10.1016/j.esmoop.2021.100216] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/18/2021] [Accepted: 06/28/2021] [Indexed: 01/27/2023] Open
Abstract
Cardiovascular adverse events induced by immune checkpoint inhibitors (ICIs) have gained significant interest over the past decade due to their impact on short- and long-term outcomes. They were initially thought to be rare, but the increasing use of ICIs in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in their incidence. Different guidelines have proposed screening measures for ICI-induced myocarditis by incorporating troponin measurements at baseline and during the first few weeks of treatment. However, no specific guidelines have been developed yet regarding the interpretation of an asymptomatic rise in troponins. This state-of-the art review aims to provide an overview of the clinical relevance of elevated troponins during checkpoint inhibition and recommendations on how to manage elevated troponin levels during ICI therapy.
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Affiliation(s)
- D Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium.
| | - D Vervloet
- Department of Cardiology, AZ Maria Middelares, Ghent, Belgium
| | - C Franssen
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - L Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
| | - F Gremonprez
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - H Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - M Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - C Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
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26
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Zhu H, Ivanovic M, Nguyen A, Nguyen PK, Wu SM. Immune checkpoint inhibitor cardiotoxicity: Breaking barriers in the cardiovascular immune landscape. J Mol Cell Cardiol 2021; 160:121-127. [PMID: 34303670 DOI: 10.1016/j.yjmcc.2021.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/28/2021] [Accepted: 07/17/2021] [Indexed: 12/14/2022]
Abstract
Immune checkpoint inhibitors (ICI) have changed the landscape of cancer therapy, but their use carries a high risk of cardiac immune related adverse events (iRAEs). With the expanding utilization of ICI therapy, there is a growing need to understand the underlying mechanisms behind their anti-tumor activity as well as their immune-mediated toxicities. In this review, we will focus on clinical characteristics and immune pathways of ICI cardiotoxicity, with an emphasis on single-cell technologies used to gain insights in this field. We will focus on three key areas of ICI-mediated immune pathways, including the anti-tumor immune response, the augmentation of the immune response by ICIs, and the pathologic "autoimmune" response in some individuals leading to immune-mediated toxicity, as well as local factors in the myocardial immune environment predisposing to autoimmunity. Discerning the underlying mechanisms of these immune pathways is necessary to inform the development of targeted therapies for ICI cardiotoxicities and reduce treatment related morbidity and mortality.
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Affiliation(s)
- Han Zhu
- Department of Medicine, Stanford University, Stanford, California 94305, USA; Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Maja Ivanovic
- Department of Medicine, Stanford University, Stanford, California 94305, USA
| | - Andrew Nguyen
- Department of Medicine, Stanford University, Stanford, California 94305, USA
| | - Patricia K Nguyen
- Department of Medicine, Stanford University, Stanford, California 94305, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA.
| | - Sean M Wu
- Department of Medicine, Stanford University, Stanford, California 94305, USA; Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA.
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27
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Puzanov I, Subramanian P, Yatsynovich YV, Jacobs DM, Chilbert MR, Sharma UC, Ito F, Feuerstein SG, Stefanovic F, Switzer B, Hicar MD, Curtis AB, Spangenthal EJ, Dy GK, Ernstoff MS, Vachhani P, Page BJ, Agrawal N, Khunger A, Kapoor A, Hattoum A, Jerome SJ. Clinical characteristics, time course, treatment and outcomes of patients with immune checkpoint inhibitor-associated myocarditis. J Immunother Cancer 2021; 9:jitc-2021-002553. [PMID: 34162715 PMCID: PMC8231054 DOI: 10.1136/jitc-2021-002553] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Immune checkpoint inhibitors (ICI) have emerged as a front-line therapy for a variety of solid tumors. With the widespread use of these agents, immune-associated toxicities are increasingly being recognized, including fatal myocarditis. There are limited data on the outcomes and prognostic utility of biomarkers associated with ICI-associated myocarditis. Our objective was to examine the associations between clinical biomarkers of cardiomyocyte damage and mortality in patients with cancer treated with ICIs. Methods We retrospectively studied 23 patients who developed symptomatic and asymptomatic troponin elevations while receiving ICI therapy at a National Cancer Institute-designated comprehensive cancer center. We obtained serial ECGs, troponin I, and creatine kinase-MD (CK-MB), in addition to other conventional clinical biomarkers, and compared covariates between survivors and non-survivors. Results Among patients with myocarditis, higher troponin I (p=0.037) and CK-MB (p=0.034) levels on presentation correlated with progression to severe myocarditis. Higher troponin I (p=0.016), CK (p=0.013), and CK-MB (p=0.034) levels were associated with increased mortality, while the presence of advanced atrioventricular block on presentation (p=0.088) trended toward increased mortality. Weekly troponin monitoring lead to earlier hospitalization for potential myocarditis (p=0.022) and was associated with decreased time to steroid initiation (p=0.053) and improved outcomes. Conclusions Routine troponin surveillance may be helpful in predicting mortality in ICI-treated patients with cancer in the early phase of ICI therapy initiation. Early detection of troponin elevation is associated with earlier intervention and improved outcomes in ICI-associated myocarditis. The recommended assessment and diagnostic studies guiding treatment decisions are presented.
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Affiliation(s)
- Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | | | - Yan V Yatsynovich
- Department of Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - David M Jacobs
- CPL Associates, Buffalo, New York, USA.,Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Maya R Chilbert
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Umesh C Sharma
- Department of Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Fumito Ito
- Center for Immunotherapy, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.,Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Steven G Feuerstein
- CPL Associates, Buffalo, New York, USA.,Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Filip Stefanovic
- CPL Associates, Buffalo, New York, USA.,Department of Biomedical Engineering, University at Buffalo School of Engineering and Applied Sciences, Buffalo, New York, USA
| | - Benjamin Switzer
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Mark D Hicar
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Anne B Curtis
- Department of Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Edward J Spangenthal
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Grace K Dy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Marc S Ernstoff
- Division of Cancer Treatment and Diagnosis/Developmental Therapeutics Program, National Cancer Institute, Rockville, Maryland, USA
| | - Pankit Vachhani
- Department of Medicine, Division of Hematology and Oncology, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Brian J Page
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Nikhil Agrawal
- Department of Cardiovascular Medicine, The University of Texas at Houston/MD Anderson Cancer Center, Houston, Texas, USA
| | - Arjun Khunger
- Department of Internal Medicine, Memorial Hospital West, Pembroke Pines, Florida, USA
| | - Ankita Kapoor
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Alexander Hattoum
- Department of Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Schentag J Jerome
- CPL Associates, Buffalo, New York, USA.,Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
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28
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Gong FF, Cascino GJ, Murtagh G, Akhter N. Circulating Biomarkers for Cardiotoxicity Risk Prediction. Curr Treat Options Oncol 2021; 22:46. [PMID: 33866434 DOI: 10.1007/s11864-021-00845-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 01/22/2023]
Abstract
OPINION STATEMENT Improvements in cancer survival have led to the emergence of cardiovascular disease as an important determinant of adverse outcome in survivors. Cancer therapeutics-related cardiac dysfunction is the most well-known form of cardiotoxicity. However, newer cancer therapies bring a broader range of cardiotoxicities. The optimal method to identify patients at risk of these complications is unclear, but circulating biomarkers comprise one possible approach. Troponins and natriuretic peptides have garnered the broadest evidence base for cardiotoxicity risk prediction, but other markers are being investigated. In this review, we explore evidence for circulating biomarkers in cardiotoxicity prediction associated with cancer therapies.
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Affiliation(s)
- Fei Fei Gong
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 600, Chicago, IL, 60611, USA
| | - Gregory J Cascino
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 600, Chicago, IL, 60611, USA
| | - Gillian Murtagh
- Diagnostics Division, Abbott Laboratories, 100 Abbott Park Road, CP1-3, Abbott Park, North Chicago, IL, 60064-6094, USA
| | - Nausheen Akhter
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 600, Chicago, IL, 60611, USA.
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29
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Petricciuolo S, Delle Donne MG, Aimo A, Chella A, De Caterina R. Pre-treatment high-sensitivity troponin T for the short-term prediction of cardiac outcomes in patients on immune checkpoint inhibitors. Eur J Clin Invest 2021; 51:e13400. [PMID: 32894777 DOI: 10.1111/eci.13400] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/09/2020] [Accepted: 09/01/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are an emerging option for several advanced metastatic cancers, but may have cardiotoxic effects. The prognostic value of high-sensitivity troponin T (hs-TnT) before treatment start has never been investigated. MATERIALS AND METHODS Thirty consecutive patients underwent measurement of hs-TnT before starting ICI therapy (pembrolizumab, 23%; nivolumab, 12%; atezolizumab, 6%; durvalumab, 5%). The primary endpoint of cardiovascular death, stroke or transient ischaemic attack, pulmonary embolism and new-onset heart failure, and the secondary endpoint of progression of cardiac involvement according to the CARDIOTOX classification were evaluated after 3 months from the first cycle. RESULTS Patients (median age 68 years, 77% men, 13% with coronary artery disease, 90% current or former smokers, 67% overweight or obese and 43% hypertensive) had a median hs-TnT of 12 ng/L (interquartile interval 8-23). The primary endpoint occurred only in patients with hs-TnT ≥ 14 ng/L at baseline. Therefore, only patients who had hs-TnT ≥ 14 ng/L before the first cycle died had a stroke/TIA or new-onset HF. Furthermore, nine out of 13 patients with the secondary endpoint (progression of cardiac disease) had hs-TnT ≥ 14 ng/L before the first cycle (P = .012). AUC values were 0.909 for the primary endpoint and 0.757 for the secondary endpoint. The best cut-off was 14 ng/L for both the primary (100% sensitivity, 73% specificity) and secondary endpoints (sensitivity 75%, specificity 77%). CONCLUSIONS In patients on ICIs, baseline hs-TnT predicts a composite cardiovascular endpoint and the progression of cardiac involvement at 3 months, with 14 ng/L as the best cut-off.
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Affiliation(s)
| | | | - Alberto Aimo
- Cardiology Division, Pisa University Hospital, Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Antonio Chella
- Pneumo-Oncology Unit, Pisa University Hospital, Pisa, Italy
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30
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Mechanisms and clinical manifestations of cardiovascular toxicities associated with immune checkpoint inhibitors. Clin Sci (Lond) 2021; 135:703-724. [PMID: 33686402 DOI: 10.1042/cs20200331] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 12/17/2022]
Abstract
Immunotherapies have greatly expanded the armamentarium of cancer-directed therapies in the past decade, allowing the immune system to recognize and fight cancer. Immune checkpoint inhibitors (ICIs), in particular, have revolutionized cancer treatment and have demonstrated survival benefit in numerous types of cancer. These monoclonal antibodies increase anti-cancer immunity by blocking down-regulators of adaptive immunity, including cytotoxic T lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), and its ligand (PD-L1), resulting in anti-tumor activity. As ICIs increase immune system activation, they can cause a wide range of inflammatory side effects, termed immune-released adverse events. Though these toxicities can affect nearly any organ, the most fatal toxicity is myocarditis. Here, we discuss the diverse spectrum of cardiovascular toxicities associated with ICI use. In addition, we provide insight and future directions on mechanisms and treatments for immune-related adverse events (irAEs) involving the myocardium, pericardium, vasculature, and conduction system.
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31
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Zlotoff DA, Hassan MZO, Zafar A, Alvi RM, Awadalla M, Mahmood SS, Zhang L, Chen CL, Ederhy S, Barac A, Banerji D, Jones-O'Connor M, Murphy SP, Armanious M, Forrestal BJ, Kirchberger MC, Coelho-Filho OR, Rizvi MA, Sahni G, Mandawat A, Tocchetti CG, Hartmann S, Gilman HK, Zatarain-Nicolás E, Mahmoudi M, Gupta D, Sullivan R, Ganatra S, Yang EH, Heinzerling LM, Thuny F, Zubiri L, Reynolds KL, Cohen JV, Lyon AR, Groarke J, Thavendiranathan P, Nohria A, Fradley MG, Neilan TG. Electrocardiographic features of immune checkpoint inhibitor associated myocarditis. J Immunother Cancer 2021; 9:jitc-2020-002007. [PMID: 33653803 PMCID: PMC7929895 DOI: 10.1136/jitc-2020-002007] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 02/07/2023] Open
Abstract
Background Myocarditis is a highly morbid complication of immune checkpoint inhibitor (ICI) use that remains inadequately characterized. The QRS duration and the QTc interval are standardized electrocardiographic measures that are prolonged in other cardiac conditions; however, there are no data on their utility in ICI myocarditis. Methods From an international registry, ECG parameters were compared between 140 myocarditis cases and 179 controls across multiple time points (pre-ICI, on ICI prior to myocarditis, and at the time of myocarditis). The association between ECG values and major adverse cardiac events (MACE) was also tested. Results Both the QRS duration and QTc interval were similar between cases and controls prior to myocarditis. When compared with controls on an ICI (93±19 ms) or to baseline prior to myocarditis (97±19 ms), the QRS duration prolonged with myocarditis (110±22 ms, p<0.001 and p=0.009, respectively). In contrast, the QTc interval at the time of myocarditis (435±39 ms) was not increased compared with pre-myocarditis baseline (422±27 ms, p=0.42). A prolonged QRS duration conferred an increased risk of subsequent MACE (HR 3.28, 95% CI 1.98 to 5.62, p<0.001). After adjustment, each 10 ms increase in the QRS duration conferred a 1.3-fold increase in the odds of MACE (95% CI 1.07 to 1.61, p=0.011). Conversely, there was no association between the QTc interval and MACE among men (HR 1.33, 95% CI 0.70 to 2.53, p=0.38) or women (HR 1.48, 95% CI 0.61 to 3.58, p=0.39). Conclusions The QRS duration is increased in ICI myocarditis and is associated with increased MACE risk. Use of this widely available ECG parameter may aid in ICI myocarditis diagnosis and risk-stratification.
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Affiliation(s)
- Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amna Zafar
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raza M Alvi
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Magid Awadalla
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Syed S Mahmood
- Cardio-Oncology Program, Cardiology Division, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Lili Zhang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Stephane Ederhy
- Cardio-Oncology Program, Division of Cardiology, Hopitaux Universitaires Est Parisien, Paris, France
| | - Ana Barac
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Dahlia Banerji
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maeve Jones-O'Connor
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sean P Murphy
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Merna Armanious
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, Tampa, Florida, USA
| | - Brian J Forrestal
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Otavio R Coelho-Filho
- Discipline of Cardiology, Department of Medicine, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, Pennsylvania, USA
| | - Gagan Sahni
- Cardiology Division, Mount Sinai Medical Center, New York, New York, USA
| | - Anant Mandawat
- Cardio-Oncology Program, Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Interdepartmental Center of Clinical and Translational Research (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Università degli Studi di Napoli Federico II, Naples, Italy
| | - Sarah Hartmann
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hannah K Gilman
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eduardo Zatarain-Nicolás
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | | | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Ryan Sullivan
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | | | - Franck Thuny
- Mediterranean University Center of Cardio-Oncology, Aix-Marseille University, North Hospital, Marseille, France
| | - Leyre Zubiri
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Justine V Cohen
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital and Imperial College London, London, UK
| | - John Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, Tampa, Florida, USA
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA .,Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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32
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Xu S, Sharma UC, Tuttle C, Pokharel S. Immune Checkpoint Inhibitors: Cardiotoxicity in Pre-clinical Models and Clinical Studies. Front Cardiovasc Med 2021; 8:619650. [PMID: 33614750 PMCID: PMC7887301 DOI: 10.3389/fcvm.2021.619650] [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: 10/20/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
Since the approval of the first immune checkpoint inhibitor (ICI) 9 years ago, ICI-therapy have revolutionized cancer treatment. Lately, antibodies blocking the interaction of programmed cell death protein (PD-1) and ligand (PD-L1) are gaining momentum as a cancer treatment, with multiple agents and cancer types being recently approved for treatment by the US Food and Drug Administration (FDA). Unfortunately, immunotherapy often leads to a wide range of immune related adverse events (IRAEs), including several severe cardiac effects and most notably myocarditis. While increased attention has been drawn to these side effects, including publication of multiple clinical observational data, the underlying mechanisms are unknown. In the event of IRAEs, the most widely utilized clinical solution is administration of high dose corticosteroids and in severe cases, discontinuation of these ICIs. This is detrimental as these therapies are often the last line of treatment options for many types of advanced cancer. In this review, we have systematically described the pathophysiology of the PD-1/PD-L1 axis (including a historical perspective) and cardiac effects in pre-clinical models, clinical trials, autoimmune mechanisms, and immunotherapy in combination with other cancer treatments. We have also reviewed the current challenges in the diagnosis of cardiac events and future directions in the field. In conclusion, this review will delve into this expanding field of cancer immunotherapy and the emerging adverse effects that should be quickly detected and prevented.
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Affiliation(s)
- Shirley Xu
- Division of Thoracic Pathology and Oncology, Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States.,Department of Medicine, Jacob's School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States
| | - Umesh C Sharma
- Department of Medicine, Jacob's School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States
| | - Cheyanna Tuttle
- Division of Thoracic Pathology and Oncology, Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Saraswati Pokharel
- Division of Thoracic Pathology and Oncology, Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
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Ederhy S, Benhamou-Tarallo I, Chauvet-Droit M, Nhan P, Cohen R, Pinna B, Cholet C, Fenioux C, Champiat S, Salem JE, Soulat-Dufour L, Cohen AA. Cardiotoxicity Related to Immune Checkpoint Inhibitors. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00878-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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34
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Nso N, Antwi-Amoabeng D, Beutler BD, Ulanja MB, Ghuman J, Hanfy A, Nimo-Boampong J, Atanga S, Doshi R, Enoru S, Gullapalli N. Cardiac adverse events of immune checkpoint inhibitors in oncology patients: A systematic review and meta-analysis. World J Cardiol 2020; 12:584-598. [PMID: 33312443 PMCID: PMC7701899 DOI: 10.4330/wjc.v12.i11.584] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/12/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are novel therapeutic agents used for various types of cancer. ICIs have revolutionized cancer treatment and improved clinical outcomes among cancer patients. However, immune-related adverse effects of ICI therapy are common. Cardiovascular immune-related adverse events (irAEs) are rare but potentially life-threatening complications.
AIM To estimate the incidence of cardiovascular irAEs among patients undergoing ICI therapy for various malignancies.
METHODS We conducted this systematic review and meta-analysis by searching PubMed, Cochrane CENTRAL, Web of Science, and SCOPUS databases for relevant interventional trials reporting cardiovascular irAEs. We performed a single-arm meta-analysis using OpenMeta [Analyst] software of the following outcomes: Myocarditis, pericardial effusion, heart failure, cardiomyopathy, atrial fibrillation, myocardial infarction, and cardiac arrest. We assessed the heterogeneity using the I2 test and managed to solve it with Cochrane’s leave-one-out method. The risk of bias was performed with the Cochrane’s risk of bias tool.
RESULTS A total of 26 studies were included. The incidence of irAEs follows: Myocarditis: 0.5% [95% confidence interval (CI): 0.1%-0.9%]; Pericardial effusion: 0.5% (95%CI: 0.1%-1.0%); Heart failure: 0.3% (95%CI: 0.0%-0.5%); Cardiomyopathy: 0.3% (95%CI: -0.1%-0.6%); atrial fibrillation: 4.6% (95%CI: 1.0%-14.1%); Myocardial infarction: 0.4% (95%CI: 0.0%-0.7%); and Cardiac arrest: 0.4% (95%CI: 0.1%-0.8%).
CONCLUSION The most common cardiovascular irAEs were atrial fibrillation, myocarditis, and pericardial effusion. Although rare, data from post market surveillance will provide estimates of the long-term prevalence and prognosis in patients with ICI-associated cardiovascular complications.
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Affiliation(s)
- Nso Nso
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Queens, NY 10029, United States
| | - Daniel Antwi-Amoabeng
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, NV 89502, United States
| | - Bryce D Beutler
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Mark B Ulanja
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, NV 89502, United States
| | - Jasmine Ghuman
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, NV 89502, United States
| | - Ahmed Hanfy
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, NV 89502, United States
| | - Joyce Nimo-Boampong
- Department of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Sirri Atanga
- Department of Medicine, United Health Services Wilson Medical Center, Johnson City, NY 13790, United States
| | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, NV 89502, United States
| | - Sostanie Enoru
- Department of Cardiovascular Disease, SUNY Downstate Health Science University, Brooklyn, NY 11203, United States
| | - Nageshwara Gullapalli
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, NV 89502, United States
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Abstract
Purpose of review Contemporary anticancer immunotherapy, particularly immune checkpoint inhibitors (ICI) and chimeric antigen receptor (CAR) T cell therapy, has changed the landscape of treatment for patients with a variety of malignancies who historically had a poor prognosis. However, both immune checkpoint inhibitors and CAR T cell therapy are associated with serious cardiovascular adverse effects. As immunotherapy evolves to include high-risk patients with preexisting cardiovascular risk factors and disease, the risk and relevance of its associated cardiotoxicity will be even higher. Recent findings ICI can cause myocarditis, which usually occurs early after initiation, can be fulminant, and prompt treatment with high-dose corticosteroids is crucial. CAR T cell therapy frequently leads to cytokine release syndrome, which is associated with cardiomyopathy or arrhythmia development and may also result in circulatory collapse. Supportive treatment, as well as tocilizumab, an anti-interleukin-6 receptor antibody, is the cornerstone of treatment. Recent findings suggest that preexisting cardiovascular risk factors and disease may increase the risk of such cardiotoxicity, and prompt recognition, as well as treatment, may favorably alter the outcomes. Summary ICI and CAR T cell therapy have improved cancer-related outcomes; however, they both are associated with potentially therapy-limiting cardiotoxicity. Cardio-oncologists are required to play an important role in patient selection, pretherapy cardiovascular optimization, and prompt recognition and treatment of cardiotoxicity.
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Ziadi MC, de Kemp R, Beanlands RSB, Small GR. Looking for trouble: Reduced myocardial flow reserve following anthracyclines. J Nucl Cardiol 2020; 27:1708-1713. [PMID: 30627882 DOI: 10.1007/s12350-018-01564-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 01/06/2023]
Affiliation(s)
- M C Ziadi
- Non Invasive Cardiovascular Imaging Department, Instituto Cardiovascular de Rosario, 440 Oroño Boulevard, Rosario, Santa Fe, Argentina.
| | - Rob de Kemp
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Rob S B Beanlands
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - G R Small
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Su C, Wang H, Liu Y, Guo Q, Zhang L, Li J, Zhou W, Yan Y, Zhou X, Zhang J. Adverse Effects of Anti-PD-1/PD-L1 Therapy in Non-small Cell Lung Cancer. Front Oncol 2020; 10:554313. [PMID: 33072580 PMCID: PMC7531287 DOI: 10.3389/fonc.2020.554313] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/14/2020] [Indexed: 12/19/2022] Open
Abstract
Currently, immunotherapy has shown great efficacy in clinical trials, and monoclonal antibodies directed against immune checkpoint PD-1/PD-L1 have shown encouraging results in first-line or second-line treatment of non-small cell lung cancer patients. Meanwhile, anti-PD-1/PD-L1 immune checkpoint drugs combined with other treatments, such as chemotherapy, targeted therapy as well as anti-CTLA-4 checkpoint therapy, are considered an attractive treatment with higher efficacy. However, toxicity associated with PD-1/PD-L1 blockade is worth attention. Understanding the adverse effects caused by anti-PD-1/PD-L1 immunosuppressive agents is vital to guide the clinical rational use of drug. In this review, we summarized the adverse effects that occurred during the clinical use of anti-PD-1/PD-L1 inhibitors in the treatment of non-small cell lung cancer and discussed how to effectively manage and respond to these adverse reactions.
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Affiliation(s)
- Chaoyue Su
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China.,School of Public Health, Hainan Medical University, Haikou, China
| | - Hui Wang
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China.,Guangzhou Institute of Pediatrics/Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yunru Liu
- School of Public Health, Hainan Medical University, Haikou, China
| | - Qiaoru Guo
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Lingling Zhang
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Jiajun Li
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Wenmin Zhou
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Yanyan Yan
- Institute of Immunology and School of Medicine, Shanxi Datong University, Datong, China
| | - Xinke Zhou
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Jianye Zhang
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China.,School of Public Health, Hainan Medical University, Haikou, China
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38
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Concomitant development of neurologic and cardiac immune-related adverse effects in patients treated with immune checkpoint inhibitors for melanoma. Melanoma Res 2020; 30:484-491. [PMID: 32898389 DOI: 10.1097/cmr.0000000000000681] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Immune checkpoint inhibitors (ICI) have altered the prognosis of patients with melanoma over the past few years, with immune-related adverse effects (irAEs) being the only factor limiting their use. Neurologic and cardiac irAEs are rare, but usually severe. We reviewed the files of patients with melanoma treated with ICIs in one center to retrieve data from patients with neurologic irAEs. Patients with a combination of neurologic and cardiac manifestations were further analyzed. We also reviewed the literature for similar syndromes. Five out of 482 (1.01%) patients developed a neurologic syndrome and we present three patients with a constellation of neurologic and cardiac irAEs. A 66-year-old woman and a 68-year-old man presented with a constellation of findings after being treated with ipilimumab and nivolumab, respectively, for melanoma in the adjuvant setting and were eventually diagnosed with myasthenia gravis with cardiac involvement. An 80-year-old woman developed diffuse asymmetric muscle weakness, bilateral ptosis and asymptomatic high serum troponin levels after adjuvant treatment with nivolumab and ipilimumab for a stage IIIB melanoma. After excluding ischemic heart disease, she was diagnosed with axonal polyradiculoneuropathy and myocarditis. Neurologic or cardiac irAEs in patients treated with ICIs are uncommon (<1%), but usually severe, with high rates of morbidity and fatality. The co-development of neurologic and cardiac irAEs is even more rare and can arise soon after exposure to ICIs and escalate rapidly. Since more and more patients are now treated with ICIs in the adjuvant setting, prompt identification and management are essential to avoid serious complications or death.
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39
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Moey MY, Tomdio AN, McCallen JD, Vaughan LM, O’Brien K, Naqash AR, Cherry C, Walker PR, Carabello BA. Characterization of Immune Checkpoint Inhibitor-Related Cardiotoxicity in Lung Cancer Patients From a Rural Setting. JACC CardioOncol 2020; 2:491-502. [PMID: 34396256 PMCID: PMC8352337 DOI: 10.1016/j.jaccao.2020.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI)-related cardiotoxicity (iRC) is uncommon but can be fatal. There have been few reports of iRC from a rural cancer population and few data for iRC and inflammatory biomarkers. OBJECTIVES The purpose of this study was to characterize major adverse cardiac events (MACE) in ICI-treated lung cancer patients based in a rural setting and to assess the utility of C-reactive protein (CRP) and neutrophil-lymphocyte ratio (NLR) in the diagnosis of iRC. METHODS Patients with lung cancer treated with ICIs at Vidant Medical Center/East Carolina University (VMC/ECU) between 2015 and 2018 were retrospectively identified. MACE included myocarditis, non-ST-segment elevated myocardial infarction (NSTEMI), supraventricular tachycardia (SVT), and pericardial disorders. Medical history, laboratory values, pre-ICI electrocardiography (ECG), and echocardiography results were compared in patients with and without MACE. RESULTS Among 196 ICI-treated patients, 23 patients (11%) developed MACE at a median of 46 days from the first ICI infusion (interquartile range [IQR]: 17 to 83 days). Patients who developed MACE experienced myocarditis (n = 9), NSTEMI (n = 3), SVT (n = 7), and pericardial disorders (n = 4). Ejection fraction was not significantly different at the time of MACE compared to that at baseline (p = 0.495). Compared to baseline values, NLR (10.9 ± 8.3 vs. 20.7 ± 4.2, respectively; p = 0.032) and CRP (42.1 ± 10.1 mg/l vs. 109.9 ± 15.6 mg/l, respectively; p = 0.010) were significantly elevated at the time of MACE. CONCLUSIONS NLR and CRP were significantly elevated at the time of MACE compared to baseline values in ICI-treated patients. Larger datasets are needed to validate these findings and identify predictors of MACE that can be used in the diagnosis and management of ICI-related iRC.
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Key Words
- CAR T, chimeric antigen receptor T cell
- CTCAE, common terminology for clinical adverse events
- CTLA-4, cytotoxicity T-cell lymphocyte antigen
- ICI, immune checkpoint inhibitor
- MACE, major adverse cardiac events
- NLR, neutrophil-to-lymphocyte ratio
- NSCLC, non-small cell lung cancer
- PD, programmed cell death
- PD-L1, programmed cell death-ligand 1
- iRC, immune checkpoint inhibitor-related cardiotoxicity
- immune checkpoint inhibitors
- inflammatory markers
- irAE, immune-related adverse events
- myocarditis
- neutrophil-to-lymphocyte ratio
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Affiliation(s)
- Melissa Y.Y. Moey
- Department of Cardiovascular Sciences, Vidant Medical Center, East Carolina University, Greenville, North Carolina, USA
| | - Anna N. Tomdio
- Department of Cardiovascular Sciences, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Justin D. McCallen
- Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Lauren M. Vaughan
- Department of Internal Medicine, Vidant Medical Center, East Carolina University, Greenville, North Carolina, USA
| | - Kevin O’Brien
- Department of Biostatistics, East Carolina University, Greenville, North Carolina, USA
| | - Abdul R. Naqash
- Department of Hematology and Oncology, Vidant Medical Center, East Carolina University, Greenville, North Carolina, USA
- U.S. National Institutes of Health, Bethesda, Maryland, USA
| | - Cynthia Cherry
- Department of Hematology and Oncology, Vidant Medical Center, East Carolina University, Greenville, North Carolina, USA
| | - Paul R. Walker
- Department of Hematology and Oncology, Vidant Medical Center, East Carolina University, Greenville, North Carolina, USA
| | - Blase A. Carabello
- Department of Cardiovascular Sciences, Vidant Medical Center, East Carolina University, Greenville, North Carolina, USA
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40
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Mangan BL, McAlister RK, Balko JM, Johnson DB, Moslehi JJ, Gibson A, Phillips EJ. Evolving insights into the mechanisms of toxicity associated with immune checkpoint inhibitor therapy. Br J Clin Pharmacol 2020; 86:1778-1789. [PMID: 32543711 PMCID: PMC7444794 DOI: 10.1111/bcp.14433] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022] Open
Abstract
Immune checkpoint inhibitors have emerged as a revolutionary treatment option for patients with various types of malignancy. Although these agents afford a significant improvement in outcomes for melanoma and other previously untreatable malignancies, their novel mechanism of action may predispose patients to immune-related adverse effects (irAEs). In the tumour neoantigen environment, these irAEs are due to the activation of the immune system by the blockade of suppressive checkpoints, leading to increases in T-cell activation and proliferation. IrAEs have been reported in almost any organ and at any point in time, even months to years after discontinuation of therapy. Certain populations with distinct physiological changes, genetic risk factors, and specific antigen exposures may be more highly predisposed to develop irAEs. This review discusses the incidence and mechanisms of irAEs and the relationship between host factors and irAE occurrence.
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Affiliation(s)
- Brendan L. Mangan
- Department of PharmacyVanderbilt University Medical CenterNashvilleTNUSA
| | - Renee K. McAlister
- Department of PharmacyVanderbilt University Medical CenterNashvilleTNUSA
| | - Justin M. Balko
- Department of Pathology, Microbiology and ImmunologyVanderbilt University Medical CenterNashvilleTNUSA
- Breast Cancer Research ProgramVanderbilt University Medical CenterNashvilleTNUSA
- Cancer Biology ProgramVanderbilt University Medical CenterNashvilleTNUSA
| | - Douglas B. Johnson
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Javid J. Moslehi
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Andrew Gibson
- Institute for Immunology and Infectious DiseasesMurdoch UniversityMurdochWAAustralia
| | - Elizabeth J. Phillips
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Department of Pathology, Microbiology and ImmunologyVanderbilt University Medical CenterNashvilleTNUSA
- Department of PharmacologyVanderbilt University Medical CenterNashvilleTNUSA
- Institute for Immunology and Infectious DiseasesMurdoch UniversityMurdochWAAustralia
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41
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Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of immune-mediated cardiovascular, rheumatic, and renal toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6159-6173. [PMID: 32856212 DOI: 10.1007/s00520-020-05710-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as the newest pillar of cancer treatment. Immune-mediated toxicities, stemming from increased activity within the T cell lineage, range from asymptomatic or mild complications to those that are fulminant and potentially fatal. Although they are of variable occurrence, cardiovascular, rheumatic, and renal immune-mediated toxicities are among the most serious of these adverse events. We present MASCC recommendations with respect to the workup and management of cardiovascular, rheumatic, and renal immune-mediated toxicities with a focus on presentations that require treatment with immunomodulating agents.
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42
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Cardinale DM, Zaninotto M, Cipolla CM, Passino C, Plebani M, Clerico A. Cardiotoxic effects and myocardial injury: the search for a more precise definition of drug cardiotoxicity. Clin Chem Lab Med 2020; 59:51-57. [PMID: 32845860 DOI: 10.1515/cclm-2020-0566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/06/2020] [Indexed: 12/12/2022]
Abstract
Drug-induced cardiotoxicity is a major clinical problem; cardiotoxic drugs may induce both cardiac dysfunction and myocardial injury. Several recent studies reported that cardiac troponins measured with high-sensitivity methods (hs-cTn) can enable the early detection of myocardial injury related to chemotherapy or abuse of drugs that are potentially cardiotoxic. Several authors have some concerns about the standard definition of cardiotoxicity, in particular, regarding the early evaluation of chemotherapy cardiotoxicity in cancer patients. Several recent studies using the hs-cTn assay indicate that myocardial injury may precede by some months or years the diagnosis of heart failure (HF) based on the evaluation of left ventricular ejection fraction (LVEF). Accordingly, hs-cTn assay should considered to be a reliable laboratory test for the early detection of asymptomatic or subclinical cardiotoxic damage in patients undergoing cancer chemotherapy. In accordance with the Fourth Universal Definition of Myocardial Infarction and also taking into account the recent experimental and clinical evidences, the definition of drug-cardiotoxicity should be updated considering the early evaluation of myocardial injury by means of hs-cTn assay. It is conceivable that the combined use of hs-cTn assay and cardiac imaging techniques for the evaluation of cardiotoxicity will significantly increase both diagnostic sensitivity and specificity, and also better prevent chemotherapy-related left ventricular (LV) dysfunction and other adverse cardiac events. However, large randomized clinical trials are needed to evaluate the cost/benefit ratio of standardized protocols for the early detection of cardiotoxicity using hs-cTn assay in patients receiving chemotherapy for malignant diseases.
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Affiliation(s)
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Azienda Ospedale- Università di Padova, Padova, Italy
| | - Carlo Maria Cipolla
- Cardiology Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
| | - Claudio Passino
- Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Azienda Ospedale- Università di Padova, Padova, Italy
| | - Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
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43
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Waliany S, Lee D, Witteles RM, Neal JW, Nguyen P, Davis MM, Salem JE, Wu SM, Moslehi JJ, Zhu H. Immune Checkpoint Inhibitor Cardiotoxicity: Understanding Basic Mechanisms and Clinical Characteristics and Finding a Cure. Annu Rev Pharmacol Toxicol 2020; 61:113-134. [PMID: 32776859 DOI: 10.1146/annurev-pharmtox-010919-023451] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Immune checkpoint inhibitors (ICIs) attenuate mechanisms of self-tolerance in the immune system, enabling T cell responses to cancerous tissues and revolutionizing care for cancer patients. However, by loweringbarriers against self-reactivity, ICIs often result in varying degrees of autoimmunity. Cardiovascular complications, particularly myocarditis but also arrhythmias, pericarditis, and vasculitis, have emerged as significant complications associated with ICIs. In this review, we examine the clinical aspects and basic science principles that underlie ICI-associated myocarditis and other cardiovascular toxicities. In addition, we discuss current therapeutic approaches. We believe a better mechanistic understanding of ICI-associated toxicities can lead to improved patient outcomes by reducing treatment-related morbidity.
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Affiliation(s)
- Sarah Waliany
- Department of Medicine, Stanford University, Stanford, California 94305, USA;
| | - Daniel Lee
- Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA
| | - Ronald M Witteles
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Joel W Neal
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Division of Oncology, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Patricia Nguyen
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA.,Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Mark M Davis
- Department of Microbiology and Immunology and Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, California 94305, USA.,Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Joe-Elie Salem
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, CLIP² Galilée, UNICO-GRECO Cardio-Oncology Program, and Department of Pharmacology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France.,Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA; .,Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA
| | - Sean M Wu
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA.,Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Javid J Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA; .,Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA
| | - Han Zhu
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA.,Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
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44
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Spallarossa P, Sarocchi M, Tini G, Arboscello E, Toma M, Ameri P, Porto I. How to Monitor Cardiac Complications of Immune Checkpoint Inhibitor Therapy. Front Pharmacol 2020; 11:972. [PMID: 32676031 PMCID: PMC7333217 DOI: 10.3389/fphar.2020.00972] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/15/2020] [Indexed: 12/12/2022] Open
Abstract
Immune-checkpoint inhibitors (ICIs) represent a successful paradigm in the treatment of cancer. ICIs elicit an immune response directed against cancer cells, by targeting the so-called immune checkpoints, key regulators of the immune system that when stimulated can dampen the immune response to an immunologic stimulus. Such response, however, is not entirely tumor-specific and may result in immune-related adverse events (irAEs), involving a number of organs and systems. Cardiovascular (CV) irAEs are rare, although potentially severe. In particular, several cases of ICI-related myocarditis with life-threatening course have been reported: the possibility of fulminant cases, thus, requires a high level of awareness among both oncologists and cardiologists. Aggressive work-up and management of symptomatic patients taking ICIs is fundamental for early recognition and initiation of specific immunosuppressive therapies. Notably, myocarditis occurs within few weeks from ICIs initiation, offering opportunity for a targeted screening. Troponin testing is the cornerstone of this screening, yet uncertainties remain regarding timing and candidates. Moreover, troponins positivity should be carefully interpreted. We herein review the main aspects of ICI-related myocarditis and suggest a practical approach. In particular, we focus on the opportunities that a baseline CV evaluation offers for subsequent management by collecting clinical and instrumental data, essential for the interpretation of troponin results, for differential diagnosis and for the formulation of a diagnostic and therapeutic workup.
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Affiliation(s)
- Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS San Martino Policlinic Hospital–IRCCS Italian Cardiovascular Network, Genova, Italy
| | - Matteo Sarocchi
- Cardiovascular Disease Unit, IRCCS San Martino Policlinic Hospital–IRCCS Italian Cardiovascular Network, Genova, Italy
| | - Giacomo Tini
- Cardiovascular Disease Unit, IRCCS San Martino Policlinic Hospital–IRCCS Italian Cardiovascular Network, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Eleonora Arboscello
- Department of Emergency, IRCCS San Martino Policlinic Hospital, University of Genova, Genova, Italy
| | - Matteo Toma
- Cardiovascular Disease Unit, IRCCS San Martino Policlinic Hospital–IRCCS Italian Cardiovascular Network, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS San Martino Policlinic Hospital–IRCCS Italian Cardiovascular Network, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Italo Porto
- Cardiovascular Disease Unit, IRCCS San Martino Policlinic Hospital–IRCCS Italian Cardiovascular Network, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
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45
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First-In-Class CD13-Targeted Tissue Factor tTF-NGR in Patients with Recurrent or Refractory Malignant Tumors: Results of a Phase I Dose-Escalation Study. Cancers (Basel) 2020; 12:cancers12061488. [PMID: 32517329 PMCID: PMC7352358 DOI: 10.3390/cancers12061488] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Aminopeptidase N (CD13) is present on tumor vasculature cells and some tumor cells. Truncated tissue factor (tTF) with a C-terminal NGR-peptide (tTF-NGR) binds to CD13 and causes tumor vascular thrombosis with infarction. Methods: We treated 17 patients with advanced cancer beyond standard therapies in a phase I study with tTF-NGR (1-h infusion, central venous access, 5 consecutive days, and rest periods of 2 weeks). The study allowed intraindividual dose escalations between cycles and established Maximum Tolerated Dose (MTD) and Dose-Limiting Toxicity (DLT) by verification cohorts. Results: MTD was 3 mg/m2 tTF-NGR/day × 5, q day 22. DLT was an isolated and reversible elevation of high sensitivity (hs) Troponin T hs without clinical sequelae. Three thromboembolic events (grade 2), tTF-NGR-related besides other relevant risk factors, were reversible upon anticoagulation. Imaging by contrast-enhanced ultrasound (CEUS) and dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) showed major tumor-specific reduction of blood flow in all measurable lesions as proof of principle for the mode of action of tTF-NGR. There were no responses as defined by Response Evaluation Criteria in Solid Tumors (RECIST), although some lesions showed intratumoral hemorrhage and necrosis after tTF-NGR application. Pharmacokinetic analysis showed a t1/2(terminal) of 8 to 9 h without accumulation in daily administrations. Conclusion: tTF-NGR is safely applicable with this regimen. Imaging showed selective reduction of tumor blood flow and intratumoral hemorrhage and necrosis.
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46
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Clerico A, Cardinale DM, Zaninotto M, Aspromonte N, Sandri MT, Passino C, Migliardi M, Perrone M, Fortunato A, Padoan A, Trenti T, Bernardini S, Sciacovelli L, Colivicchi F, Gabrielli D, Plebani M. High-sensitivity cardiac troponin I and T methods for the early detection of myocardial injury in patients on chemotherapy. Clin Chem Lab Med 2020; 59:513-521. [PMID: 32441665 DOI: 10.1515/cclm-2020-0362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
Important advances achieved in pharmacological cancer treatment have led progressively to a reduction in mortality from many forms of cancer, and increasing numbers of previously incurable patients can now hope to become cancer-free. Yet, to achieve these improved outcomes a high price has been paid in terms of untoward side effects associated with treatment, cardio-toxicity in particular. Several recent studies have reported that cardiac troponin assay using high-sensitivity methods (hs-cTn) can enable the early detection of myocardial injury related to chemotherapy or abuse of drugs that are potentially cardiotoxic. Several authors have recently suggested that changes in hs-cTn values enable the early diagnosis of cardiac injury from chemotherapy, thus potentially benefitting cancer patients with increased troponin values by initiating early cardioprotective therapy. However, large randomised clinical trials are needed in order to evaluate the cost/benefit ratio of standardised protocols for the early detection of cardiotoxicity using the hs-cTn assay in patients treated with chemotherapy.
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Affiliation(s)
- Aldo Clerico
- Laboratory of Cardiovascular Endocrinology and Cell Biology, Department of Laboratory Medicine, Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | | | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, and Dipartimento di Medicina - Università di Padova, Padova, Italy
| | - Nadia Aspromonte
- Dipartimento Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario A. Gemelli IRCCS (FANMCO, FACC, Consigliere ANMCO Nazionale), Rome, Italy
| | - Maria Teresa Sandri
- Unità Operativa Laboratorio Analisi, Humanitas Medical-Care, Rozzano, Milan, Italy
| | - Claudio Passino
- Laboratory of Cardiovascular Endocrinology and Cell Biology, Department of Laboratory Medicine, Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | - Marco Migliardi
- Struttura Complessa Laboratorio Analisi, Azienda Ospedaliera Ordine Mauriziano, Torino, Italy
| | - Marco Perrone
- Dipartimento di Medicina Sperimentale, Università di Roma Tor Vergata, Rome, Italy
| | - Antonio Fortunato
- U.O.C. Patologia Clinica, ASUR Marche Area Vasta 5, Ascoli Piceno, Italy
| | - Andrea Padoan
- Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, and Dipartimento di Medicina - Università di Padova, Padova, Italy
| | - Tommaso Trenti
- Dipartimento di Medicina di Laboratorio and Anatomia Patologica, Azienda Ospedaliera Universitaria and USL di Modena, Modena, Italy
| | - Sergio Bernardini
- Dipartimento di Medicina Sperimentale, Università di Roma Tor Vergata, Rome, Italy
| | - Laura Sciacovelli
- Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, and Dipartimento di Medicina - Università di Padova, Padova, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia, P.O. San Filippo Neri - ASL Roma 1, Rome (Società Scientifica ANMCO), Roma, Italy
| | - Domenico Gabrielli
- U.O.C. Cardiologia, Ospedale Civile Augusto Murri, Fermo (Società Scientifica ANMCO), Fermo, Italy
| | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, and Dipartimento di Medicina - Università di Padova, Padova, Italy
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Leaver PJ, Jang HSI, Vernon ST, Fernando SL. Immune checkpoint inhibitor-mediated myasthenia gravis with focal subclinical myocarditis progressing to symptomatic cardiac disease. BMJ Case Rep 2020; 13:13/5/e232920. [PMID: 32404371 DOI: 10.1136/bcr-2019-232920] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The advent of immune checkpoint inhibitors (ICIs) for cancer therapy has heralded increasing frequency of immune-related adverse events including endocrinopathies, hepatitis, colitis and rarely myocarditis and myasthenia gravis (MG). The heterogeneity in clinical presentations regardless of organ-specific involvement can lead to delayed recognition and management of these events and adverse health outcomes. We describe a case of ICI-induced subclinical focal myocarditis that was recognised and treated in the broader context of MG. It is essential that patients with ICI-induced MG should be screened and monitored for myocarditis, a potentially fatal complication.
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Affiliation(s)
- Phillip John Leaver
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, New South Wales, Australia .,Department of Cardiology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Helena Sung-In Jang
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Stephen Thomas Vernon
- Department of Cardiology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Cardiothoracic and Vascular Health, Kolling Institute of Medical Research, Northern Sydney Local Health District, New South Wales, Australia.,Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Suran Loshana Fernando
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Cardiovascular toxicities of therapy for genitourinary malignancies. Urol Oncol 2020; 38:121-128. [DOI: 10.1016/j.urolonc.2019.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/12/2019] [Accepted: 04/30/2019] [Indexed: 11/22/2022]
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Bonaventura A, Grossi F, Carbone F, Vecchié A, Minetti S, Bardi N, Elia E, Ansaldo AM, Ferrara D, Rijavec E, Dal Bello MG, Rossi G, Biello F, Tagliamento M, Alama A, Coco S, Spallarossa P, Dallegri F, Genova C, Montecucco F. Resistin is associated with overall survival in non-small cell lung cancer patients during nivolumab treatment. Clin Transl Oncol 2020; 22:1603-1610. [DOI: 10.1007/s12094-020-02305-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 01/18/2020] [Indexed: 12/16/2022]
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[Third degree atrio-ventricular blockade during a myocarditis occurring under anti-PD1 : Case report and literature review]. Rev Med Interne 2020; 41:284-288. [PMID: 31983550 DOI: 10.1016/j.revmed.2019.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/01/2019] [Accepted: 12/23/2019] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Immune Checkpoint Inhibitor (ICI) therapy is now a standard of care in numerous cancers with very promising results. Nevertheless, adverse events, and especially immune-related adverse events (irAEs) not reported during clinical trials, are emerging and can be life-threatening. OBSERVATION We report here a teachable case of a 80 year-old man, of third-degree atrioventricular block consecutive to myocarditis associated with the administration of nivolumab (anti-PD1) monotherapy. CONCLUSION Myocarditis occurring during ICI treatment is a rare but potentially lethal event. Daily serum troponin level seems to predict ICI-related myocarditis but interpretation could be difficult in the context of associated myositis. Echocardiography and cardiac MRI are also useful but can remain negative. Electrocardiogram is a cornerstone of myocarditis diagnosis. In case of cardiac involvement, continuous heart rhythm monitoring should be performed in addition to the administration of high-dose corticosteroids therapy and the cessation of ICI therapy. Add-on treatments should be discussed with a well-trained multidisciplinary team.
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