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Pi JK, Chen XT, Zhang YJ, Chen XM, Wang YC, Xu JY, Zhou JH, Yu SS, Wu SS. Insight of immune checkpoint inhibitor related myocarditis. Int Immunopharmacol 2024; 143:113559. [PMID: 39536487 DOI: 10.1016/j.intimp.2024.113559] [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: 08/20/2024] [Revised: 10/20/2024] [Accepted: 10/30/2024] [Indexed: 11/16/2024]
Abstract
As the understanding of immune-related mechanisms in the development and progression of cancer advances, immunotherapies, notably Immune Checkpoint Inhibitors (ICIs), have become integral in comprehensive cancer treatment strategies. ICIs reactivate T-cell cytotoxicity against tumors by blocking immune suppressive signals on T cells, such as Programmed Death-1 (PD-1) and Cytotoxic T-lymphocyte Antigen-4 (CTLA-4). Despite their beneficial effects, ICIs are associated with immune-related adverse events (irAEs), manifesting as autoimmune side effects across various organ systems. A particularly alarming irAE is life-threatening myocarditis. This rare but severe side effect of ICIs leads to significant long-term cardiac complications, including arrhythmias and heart failure, and has been observed to have a mortality rate of up to 50% in affected patients. This greatly limits the clinical application of ICI-based immunotherapy. In this review, we provide a comprehensive summary of the current knowledge regarding the diagnosis and management of ICI-related myocarditis. We also discuss the utility of preclinical mouse models in understanding and addressing this critical challenge.
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Affiliation(s)
- Jin-Kui Pi
- Core Facilities, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Xiao-Ting Chen
- Animal Experimental Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Yan-Jing Zhang
- Core Facilities, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Xue-Mei Chen
- Core Facilities, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Yin-Chan Wang
- Core Facilities, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Jia-Yi Xu
- Core Facilities, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Jin-Han Zhou
- Core Facilities, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Shuai-Shuai Yu
- Core Facilities, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Si-Si Wu
- Core Facilities, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China.
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Vergara A, De Felice M, Cesaro A, Gragnano F, Pariggiano I, Golia E, De Pasquale A, Blasi E, Fimiani F, Monda E, Limongelli G, Calabrò P. Immune-Checkpoint Inhibitor-Related Myocarditis: Where We Are and Where We Will Go. Angiology 2024; 75:909-920. [PMID: 37699402 DOI: 10.1177/00033197231201929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are specific monoclonal antibodies directed against inhibitory targets of the immune system, mainly represented by programmed death-1 (PD1) ligand-1 (PD-L1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4), thus enabling an amplified T-cell-mediated immune response against cancer cells. These drugs have significantly improved prognosis in patients with advanced metastatic cancer (e.g., melanoma, non-small cell lung cancer, renal cell carcinoma). However, uncontrolled activation of anti-tumor T-cells could trigger an excessive immune response, possibly responsible for multi-organ damage, including, among others, lymphocytic myocarditis. The incidence of ICIs-induced myocarditis is underestimated and the patients affected are poorly characterized. The diagnosis and management of this condition are mainly based on expert opinion and case reports. EKG and ultrasound are tests that can help identify patients at risk of myocarditis during treatment by red flags, such as QRS complex enlargement and narrowing of global longitudinal strain (GLS). Therapy of ICI-related myocarditis is based on immunosuppressors, monoclonal antibodies and fusion proteins. A future strategy could involve the use of microRNAs. This review considers the current state of the art of immune-related adverse cardiovascular events, focusing on histological and clinical features, diagnosis and management, including current treatments and future pharmacological targets.
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Affiliation(s)
- Andrea Vergara
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Marco De Felice
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Caserta, Italy
- Division of Oncology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Ivana Pariggiano
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Enrica Golia
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Antonio De Pasquale
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Ettore Blasi
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Diseases, A.O.R.N. Dei Colli "V. Monaldi", Naples, Italy
| | - Emanuele Monda
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Unit of Inherited and Rare Cardiovascular Diseases, A.O.R.N. Dei Colli "V. Monaldi", Naples, Italy
| | - Giuseppe Limongelli
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Unit of Inherited and Rare Cardiovascular Diseases, A.O.R.N. Dei Colli "V. Monaldi", Naples, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
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3
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Tan S, Qi C, Zeng H, Wei Q, Huang Q, Pu X, Li W, Li Y, Tian P. Steroid-Refractory Myocarditis Induced by Immune Checkpoint Inhibitor Responded to Infliximab: Report of Two Cases and Literature Review. Cardiovasc Toxicol 2024; 24:1174-1191. [PMID: 39256296 PMCID: PMC11445312 DOI: 10.1007/s12012-024-09918-6] [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: 02/23/2024] [Accepted: 09/02/2024] [Indexed: 09/12/2024]
Abstract
Immune checkpoint inhibitors (ICIs), including anti-programmed cell death protein 1 and its ligand (PD-1/PD-L1) as well as anti-cytotoxic T lymphocyte-associated protein 4 (CTLA-4), have been widely used for treating solid tumors. Myocarditis is a potentially lethal immune-related adverse events (irAEs) caused by ICIs therapy. The treatment of steroid-refractory myocarditis is challenging. We reported two non-small-cell lung cancer patients with steroid-refractory myocarditis induced by ICI. The symptoms were not resolved after pulse corticosteroid therapy and subsequent treatment including intravenous immunoglobulin and mycophenolate mofetil. Considering the level of serum interleukin (IL)-6 decreased by > 50% and level of serum tumor necrosis factor-α (TNF-α) increased during the course of the disease, infliximab was used. Myocarditis gradually alleviated after infliximab treatment. The cases revealed that specific cytokine inhibitors have promising roles in the treatment of steroid-refractory myocarditis. Infliximab could be considered for patients with low level of IL-6 and elevated level of TNF-α.
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Affiliation(s)
- Sihan Tan
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Lung Cancer Center/Lung Cancer Institute, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, Sichuan, China
| | - Chang Qi
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Lung Cancer Center/Lung Cancer Institute, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, Sichuan, China
| | - Hao Zeng
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Lung Cancer Center/Lung Cancer Institute, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, Sichuan, China
| | - Qi Wei
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Lung Cancer Center/Lung Cancer Institute, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, Sichuan, China
| | - Qin Huang
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Lung Cancer Center/Lung Cancer Institute, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, Sichuan, China
| | - Xin Pu
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Lung Cancer Center/Lung Cancer Institute, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, Sichuan, China
| | - Weimin Li
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yalun Li
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
- Lung Cancer Center/Lung Cancer Institute, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, Sichuan, China.
| | - Panwen Tian
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
- Lung Cancer Center/Lung Cancer Institute, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, Sichuan, China.
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Fan M, Zhang X, Liu H, Li L, Wang F, Luo L, Zhou X, Liang XJ, Zhang J, Li Z. Reversing Immune Checkpoint Inhibitor-Associated Cardiotoxicity via Bioorthogonal Metabolic Engineering-Driven Extracellular Vesicle Redirecting. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2412340. [PMID: 39308257 DOI: 10.1002/adma.202412340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/12/2024] [Indexed: 11/08/2024]
Abstract
The cardiotoxicity induced by immune checkpoint inhibitors (ICIs) is associated with high mortality rates. T cells play an important role in ICI-induced cardiac injury. The inhibition of local T-cell activity is considered an effective strategy for alleviating ICI-related cardiotoxicity. Tumor-derived extracellular vesicles (EVs) contribute to immunosuppression via PD-L1 overexpression. In this study, a bioorthogonal metabolic engineering-driven EV redirecting (Biomeder) strategy for in situ engineered EVs with myocardial-targeting peptides is developed. Accumulated tumor-derived EV (TuEVs) reverses the immune environment in the heart by increasing PD-L1 levels in cardiomyocytes and/or by directly inhibiting T-cell activity. More importantly, it is found that the redirection of TuEVs further disrupts immunosuppression in tumors, which facilitates anti-tumor activity. Thus, redirecting TuEVs to the heart simultaneously enhances the antitumor efficacy and safety of ICI-based therapy. Furthermore, the Biomeder strategy is successfully expanded to prevent ICI-induced type 1 diabetes. This Biomeder technique is a universal method for the treatment of various ICI-related adverse events.
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Affiliation(s)
- Miao Fan
- The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, 523059, China
- College of Chemistry & Materials Science, Key Laboratory of Medicinal Chemistry and Molecular Diagnosis of Ministry of Education, State Key Laboratory of New Pharmaceutical Preparations and Excipients, Chemical Biology Key Laboratory of Hebei Province, Hebei University, Baoding, 071002, China
- College of Pharmacy, Hebei Medical University, Shijiazhuang, 050017, China
| | - Xing Zhang
- College of Chemistry & Materials Science, Key Laboratory of Medicinal Chemistry and Molecular Diagnosis of Ministry of Education, State Key Laboratory of New Pharmaceutical Preparations and Excipients, Chemical Biology Key Laboratory of Hebei Province, Hebei University, Baoding, 071002, China
| | - Huifang Liu
- College of Pharmaceutical Science, Key Laboratory of Pharmaceutical Quality Control of Hebei Province, Hebei University, Baoding, 071002, China
| | - Lanya Li
- The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, 523059, China
- CAS Key Laboratory for Biological Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology, Beijing, 100190, China
| | - Fei Wang
- The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, 523059, China
- CAS Key Laboratory for Biological Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology, Beijing, 100190, China
| | - Li Luo
- The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, 523059, China
- CAS Key Laboratory for Biological Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology, Beijing, 100190, China
| | - Xiaohan Zhou
- The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, 523059, China
- CAS Key Laboratory for Biological Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology, Beijing, 100190, China
| | - Xing-Jie Liang
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Southern Medical University, Guangdong, 510515, China
| | - Jinchao Zhang
- College of Chemistry & Materials Science, Key Laboratory of Medicinal Chemistry and Molecular Diagnosis of Ministry of Education, State Key Laboratory of New Pharmaceutical Preparations and Excipients, Chemical Biology Key Laboratory of Hebei Province, Hebei University, Baoding, 071002, China
| | - Zhenhua Li
- The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan, 523059, China
- CAS Key Laboratory for Biological Effects of Nanomaterials and Nanosafety, National Center for Nanoscience and Technology, Beijing, 100190, China
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5
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Gamero MT, Patel A, Storozynsky E. The Good (Tumor Killing) and the Bad (Cardiovascular Complications) of Immunologic Checkpoint Inhibitors. Curr Cardiol Rep 2024:10.1007/s11886-024-02147-x. [PMID: 39441327 DOI: 10.1007/s11886-024-02147-x] [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] [Accepted: 09/23/2024] [Indexed: 10/25/2024]
Abstract
PURPOSE OF REVIEW This review details the significant advancement in knowledge of Immune-checkpoint inhibitor (ICI) and its potential deleterious cardiac immune-related adverse effects (irAE). We explore their mechanisms on the cardiac tissue, providing guidance on risk factors, clinical presentations, diagnostic strategies along with treatment. RECENT FINDINGS Recent findings have provided insights of cardiac irAEs that exist beyond the previously well-known ICI-induced myocarditis. We have a better understanding of the wide variety of cardiac irAEs pathologies both early and late onset. Moreover, there is more data on mechanisms of cardiotoxicity and patient and therapy-related risk factors, supporting closer routine cardiac monitoring with biomarkers and imaging for prevention and early detection. Diagnosing cardiac irAEs is a challenge given its broad clinical presentation. A high-level of suspicion in addition to early work-up is crucial to prevent serious cardiac events. A multi-disciplinary team including Cardiologists and Oncologists is essential for closely monitor patients' cardiac status on ICI therapy. There is a need of updated guidelines to establish clear recommendations in patients on ICIs.
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Affiliation(s)
- Maria T Gamero
- Department of Medicine, Division of Cardiovascular Disease, Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Avish Patel
- Department of Medicine, Division of Cardiovascular Disease, Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Eugene Storozynsky
- Department of Medicine, Division of Cardiovascular Disease, Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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6
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Milutinovic S, Jancic P, Jokic V, Petrovic M, Dumic I, Rodriguez AM, Tanasijevic N, Begosh-Mayne D, Stanojevic D, Escarcega RO, Lopez-Mattei J, Cao X. Pembrolizumab-Associated Cardiotoxicity: A Retrospective Analysis of the FDA Adverse Events Reporting System. Pharmaceuticals (Basel) 2024; 17:1372. [PMID: 39459012 PMCID: PMC11510316 DOI: 10.3390/ph17101372] [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: 08/02/2024] [Revised: 10/08/2024] [Accepted: 10/11/2024] [Indexed: 10/28/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have been successfully used in the previous decade for the treatment of a variety of malignancies. Adverse events (AEs) can cause many symptoms, most notably cardiac. We analyzed the frequency of these adverse events, comparing pembrolizumab and other ICIs. METHODS Using the Food and Drug Administration (FDA) adverse event reporting database (FAERS), we searched for all adverse events of interest reported for every ICI included in this study. After obtaining the data, we conducted a disproportionality analysis using the reporting odds ratio (ROR) and the information component (IC). RESULTS A total of 6719 ICI-related cardiac adverse events of interest were reported in the database. Serious outcomes were reported in 100% of the cases, with 34.3% of the cases ending fatally. Compared with all other medications in the database, pembrolizumab use was more frequently associated with myocarditis, pericardial disease, heart failure, and atrial fibrillation. No difference was found in cardiotoxicity between different ICIs. CONCLUSIONS Although infrequent, cardiac AEs in pembrolizumab use are associated with serious outcomes and high mortality. Prospective studies are needed to further research the connection between ICI use and cardiotoxicity.
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Affiliation(s)
- Stefan Milutinovic
- Internal Medicine Residency Program at Lee Health, Florida State University College of Medicine, Cape Coral, FL 33909, USA
| | - Predrag Jancic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Vera Jokic
- Montefiore New Rochelle Hospital, New Rochelle, NY 10801, USA
| | - Marija Petrovic
- Cardiology Fellowship Program, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Ambar Morales Rodriguez
- Internal Medicine Residency Program at Lee Health, Florida State University College of Medicine, Cape Coral, FL 33909, USA
| | | | - Dustin Begosh-Mayne
- Internal Medicine Residency Program at Lee Health, Florida State University College of Medicine, Cape Coral, FL 33909, USA
| | - Dragana Stanojevic
- Clinic for Cardiology, University Clinical Center Nis, 18000 Nis, Serbia
| | - Ricardo O. Escarcega
- Internal Medicine Residency Program at Lee Health, Florida State University College of Medicine, Cape Coral, FL 33909, USA
- Lee Health Heart Institute, Fort Myers, FL 33908, USA
| | | | - Xiangkun Cao
- Lee Health Heart Institute, Fort Myers, FL 33908, USA
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7
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Sun VH, Heemelaar JC, Hadzic I, Raghu VK, Wu CY, Zubiri L, Ghamari A, LeBoeuf NR, Abu-Shawer O, Kehl KL, Grover S, Singh P, Suero-Abreu GA, Wu J, Falade AS, Grealish K, Thomas MF, Hathaway N, Medoff BD, Gilman HK, Villani AC, Ho JS, Mooradian MJ, Sise ME, Zlotoff DA, Blum SM, Dougan M, Sullivan RJ, Neilan TG, Reynolds KL. Enhancing Precision in Detecting Severe Immune-Related Adverse Events: Comparative Analysis of Large Language Models and International Classification of Disease Codes in Patient Records. J Clin Oncol 2024:JCO2400326. [PMID: 39226489 DOI: 10.1200/jco.24.00326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/20/2024] [Accepted: 06/24/2024] [Indexed: 09/05/2024] Open
Abstract
PURPOSE Current approaches to accurately identify immune-related adverse events (irAEs) in large retrospective studies are limited. Large language models (LLMs) offer a potential solution to this challenge, given their high performance in natural language comprehension tasks. Therefore, we investigated the use of an LLM to identify irAEs among hospitalized patients, comparing its performance with manual adjudication and International Classification of Disease (ICD) codes. METHODS Hospital admissions of patients receiving immune checkpoint inhibitor (ICI) therapy at a single institution from February 5, 2011, to September 5, 2023, were individually reviewed and adjudicated for the presence of irAEs. ICD codes and an LLM with retrieval-augmented generation were applied to detect frequent irAEs (ICI-induced colitis, hepatitis, and pneumonitis) and the most fatal irAE (ICI-myocarditis) from electronic health records. The performance between ICD codes and LLM was compared via sensitivity and specificity with an α = .05, relative to the gold standard of manual adjudication. External validation was performed using a data set of hospital admissions from June 1, 2018, to May 31, 2019, from a second institution. RESULTS Of the 7,555 admissions for patients on ICI therapy in the initial cohort, 2.0% were adjudicated to be due to ICI-colitis, 1.1% ICI-hepatitis, 0.7% ICI-pneumonitis, and 0.8% ICI-myocarditis. The LLM demonstrated higher sensitivity than ICD codes (94.7% v 68.7%), achieving significance for ICI-hepatitis (P < .001), myocarditis (P < .001), and pneumonitis (P = .003) while yielding similar specificities (93.7% v 92.4%). The LLM spent an average of 9.53 seconds/chart in comparison with an estimated 15 minutes for adjudication. In the validation cohort (N = 1,270), the mean LLM sensitivity and specificity were 98.1% and 95.7%, respectively. CONCLUSION LLMs are a useful tool for the detection of irAEs, outperforming ICD codes in sensitivity and adjudication in efficiency.
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Affiliation(s)
- Virginia H Sun
- Harvard Medical School, Boston, MA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA
| | - Julius C Heemelaar
- Harvard Medical School, Boston, MA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA
- Leiden University Medical Center, Leiden, the Netherlands
| | - Ibrahim Hadzic
- Harvard Medical School, Boston, MA
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Boston, MA
- Brigham and Women's Hospital, Boston, MA
- Maastricht University, Maastricht, the Netherlands
| | - Vineet K Raghu
- Harvard Medical School, Boston, MA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA
| | - Chia-Yun Wu
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Leyre Zubiri
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Azin Ghamari
- Harvard Medical School, Boston, MA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA
| | - Nicole R LeBoeuf
- Harvard Medical School, Boston, MA
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA
- Center for Cutaneous Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Osama Abu-Shawer
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Kenneth L Kehl
- Harvard Medical School, Boston, MA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Shilpa Grover
- Harvard Medical School, Boston, MA
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, MA
| | - Prabhsimranjot Singh
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Giselle A Suero-Abreu
- Harvard Medical School, Boston, MA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Jessica Wu
- Harvard Medical School, Boston, MA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA
| | - Ayo S Falade
- Internal Medicine Department, Massachusetts General Brigham Salem Hospital, Salem, MA
| | - Kelley Grealish
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Molly F Thomas
- Division of Gastroenterology, Oregon Health and Science University, Portland, OR
- Department of Medicine, Oregon Health and Science University, Portland, OR
- Department of Cell, Developmental, and Cancer Biology, Oregon Health and Science University, Portland, OR
| | - Nora Hathaway
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Benjamin D Medoff
- Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Hannah K Gilman
- Harvard Medical School, Boston, MA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA
| | - Alexandra-Chloe Villani
- Harvard Medical School, Boston, MA
- Center for Immunology and Inflammatory Diseases (CIID), Massachusetts General Hospital Krantz Family Center for Cancer Research, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Jor Sam Ho
- Harvard Medical School, Boston, MA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA
| | - Meghan J Mooradian
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Meghan E Sise
- Harvard Medical School, Boston, MA
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Daniel A Zlotoff
- Harvard Medical School, Boston, MA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Steven M Blum
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Center for Immunology and Inflammatory Diseases (CIID), Massachusetts General Hospital Krantz Family Center for Cancer Research, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Michael Dougan
- Harvard Medical School, Boston, MA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA
| | - Ryan J Sullivan
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Tomas G Neilan
- Harvard Medical School, Boston, MA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Kerry L Reynolds
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
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Keam S, Turner N, Kugeratski FG, Rico R, Colunga-Minutti J, Poojary R, Alekseev S, Patel AB, Li YJ, Sheshadri A, Loghin ME, Woodman K, Aaroe AE, Hamidi S, Iyer PC, Palaskas NL, Wang Y, Nurieva R. Toxicity in the era of immune checkpoint inhibitor therapy. Front Immunol 2024; 15:1447021. [PMID: 39247203 PMCID: PMC11377343 DOI: 10.3389/fimmu.2024.1447021] [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: 06/10/2024] [Accepted: 07/23/2024] [Indexed: 09/10/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) reinvigorate anti-tumor immune responses by disrupting co-inhibitory immune checkpoint molecules such as programmed cell death 1 (PD-1) and cytotoxic T lymphocyte antigen 4 (CTLA-4). Although ICIs have had unprecedented success and have become the standard of care for many cancers, they are often accompanied by off-target inflammation that can occur in any organ system. These immune related adverse events (irAEs) often require steroid use and/or cessation of ICI therapy, which can both lead to cancer progression. Although irAEs are common, the detailed molecular and immune mechanisms underlying their development are still elusive. To further our understanding of irAEs and develop effective treatment options, there is pressing need for preclinical models recapitulating the clinical settings. In this review, we describe current preclinical models and immune implications of ICI-induced skin toxicities, colitis, neurological and endocrine toxicities, pneumonitis, arthritis, and myocarditis along with their management.
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Affiliation(s)
- Synat Keam
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Naimah Turner
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Fernanda G Kugeratski
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rene Rico
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jocelynn Colunga-Minutti
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- The University of Texas MD Anderson Cancer Center University of Texas Health (UTHealth) Houston Graduate School of Biomedical Sciences (GSBS), Houston, TX, United States
| | | | - Sayan Alekseev
- College of Sciences, The University of Texas at San Antonio, San Antonio, TX, United States
- The Cancer Prevention and Research Institute of Texas (CPRIT)-CURE Summer Undergraduate Program, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Anisha B Patel
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Yuanteng Jeff Li
- Department of General Internal Medicine, Section of Rheumatology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Monica E Loghin
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Karin Woodman
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ashley E Aaroe
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sarah Hamidi
- Department of Endocrine Neoplasia and HD, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Priyanka Chandrasekhar Iyer
- Department of Endocrine Neoplasia and HD, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nicolas L Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Roza Nurieva
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- The University of Texas MD Anderson Cancer Center University of Texas Health (UTHealth) Houston Graduate School of Biomedical Sciences (GSBS), Houston, TX, United States
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9
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Gao Y, Zhang H, Qiu Y, Bian X, Wang X, Li Y. Early identification of severe immune checkpoint inhibitor associated myocarditis: From an electrocardiographic perspective. Cancer Med 2024; 13:e7460. [PMID: 39082198 PMCID: PMC11289619 DOI: 10.1002/cam4.7460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/28/2024] [Accepted: 06/24/2024] [Indexed: 08/02/2024] Open
Abstract
OBJECTIVES Immune checkpoint inhibitor (ICI)-associated myocarditis, particularly severe ICI-associated myocarditis, has a high mortality rate. However, the predictive value of electrocardiogram (ECG) remains unclear. The present study aimed to evaluate the predictive value of clinical and electrocardiographic parameters for severe myocarditis. METHODS Clinical and electrocardiographic data of 73 cancer patients with ICI-associated myocarditis were retrospectively collected. The severity of ICI-associated myocarditis was graded using the NCCN guidelines for managing immunotherapy-related toxicities. Myocarditis grades 1-2 and grades 3-4 were classified as mild and severe myocarditis, respectively. Logistic regression analysis was performed to analyze the predictive value of each parameter in predicting severe myocarditis. RESULTS Among the 73 patients with myocarditis, 20 (27.4%) patients had severe myocarditis. Compared with mild myocarditis group, sinus tachycardia (p = 0.001), QRS duration ≥110 ms (p = 0.001), prolonged QTc interval (p < 0.001), and bundle branch block (p = 0.007) at the time of myocarditis were more common in the severe myocarditis group. Logistic regression analysis revealed that sinus tachycardia (p = 0.028) and QTc interval prolongation (p = 0.007) were predictors of severe myocarditis. Whereas the predictive value of other electrocardiographic parameters was weak. Concurrent targeted therapy didn't increase the risk of severe myocarditis. A high NT-proBNP level was associated with severe myocarditis. CONCLUSIONS ECG at the onset of myocarditis manifested as sinus tachycardia and prolonged QTc interval predicted a high risk of severe myocarditis. Early detection of ECG abnormalities may faciliate early detection of severe ICI-associated myocarditis.
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Affiliation(s)
- Yongyin Gao
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Hongdian Zhang
- Department of Esophageal CancerTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Key Laboratory of Digestive Cancer of Tianjin, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Yanli Qiu
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Xueyan Bian
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Xue Wang
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
| | - Yue Li
- Department of Cardio‐pulmonary FunctionsTianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and therapy, Tianjin's Clinical Research Center for CancerTianjinChina
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10
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Koh YR, Cummings KC. Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations. Rheum Dis Clin North Am 2024; 50:545-557. [PMID: 38942584 DOI: 10.1016/j.rdc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.
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Affiliation(s)
- Ye Rin Koh
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA
| | - Kenneth C Cummings
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA.
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11
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Koelmeyer H, Buckley K, Feradov D, Kotch N. Complete Heart Block in a Patient Undergoing Combination Immune Checkpoint Inhibitor Therapy. Cureus 2024; 16:e66776. [PMID: 39280549 PMCID: PMC11398709 DOI: 10.7759/cureus.66776] [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: 06/27/2024] [Accepted: 08/12/2024] [Indexed: 09/18/2024] Open
Abstract
Combination immune checkpoint inhibitor (ICI) therapy is an emerging chemotherapy strategy for patients with solid tumor malignancies. Cardiotoxicity is a rare adverse effect of ICI therapy, most commonly presenting as acute myocarditis and, less frequently, as significant conduction abnormalities. We present a unique case of a 68-year-old female with urothelial cancer who developed shortness of breath and chest pain one week after receiving combination ICI therapy with ipilimumab and nivolumab. Biomarkers were elevated, including high-sensitivity troponin to 14,000 ng/L and creatine phosphokinase to 20,000 U/L. Due to suspicion of acute ICI-related myocarditis, a transthoracic echocardiogram (TTE) was obtained and demonstrated preserved ejection fraction (EF). Pulse-dose methylprednisolone therapy was initiated. However, the patient's clinical status continued to decline, and she developed bradycardia due to a complete heart block (CHB). This was initially treated with a dopamine infusion, but due to hypotension and hemodynamic instability, a transvenous pacemaker was placed. She continued to decline from a heart failure standpoint and developed acute hypoxic respiratory failure, requiring intubation due to pulmonary edema. A repeat TTE acquired three days following the initial echocardiogram demonstrated a newly reduced EF of 30%-35%. Additional anti-inflammatory agents were administered, including mycophenolate, infliximab, and anti-thymocyte globulin, with little improvement in clinical status. Unfortunately, she rapidly deteriorated, resulting in pulseless electrical activity (PEA) arrest and circulatory death. The autopsy revealed severe biventricular myocarditis with partial involvement of the atrioventricular node, consistent with her clinical syndrome of acute heart failure and CHB. A literature review demonstrated very few cases of ICI-related CHB. This case highlights a rare instance of atrioventricular dissociation in a patient with cardiotoxicity due to combination ICI therapy.
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Affiliation(s)
- Himara Koelmeyer
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Kinley Buckley
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Denise Feradov
- Cardiovascular Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Nicholas Kotch
- Electrophysiology, University of South Florida Morsani College of Medicine, Tampa, USA
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12
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Buehning F, Lerchner T, Vogel J, Hendgen-Cotta UB, Totzeck M, Rassaf T, Michel L. Preclinical models of cardiotoxicity from immune checkpoint inhibitor therapy. Basic Res Cardiol 2024:10.1007/s00395-024-01070-0. [PMID: 39039301 DOI: 10.1007/s00395-024-01070-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/30/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024]
Abstract
Immune checkpoint inhibitor (ICI) therapy represents a ground-breaking paradigm in cancer treatment, harnessing the immune system to combat malignancies by targeting checkpoints such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1). The use of ICI therapy generates distinctive immune-related adverse events (irAEs) including cardiovascular toxicity, necessitating targeted research efforts. This comprehensive review explores preclinical models dedicated to ICI-mediated cardiovascular complications including myocarditis. Tailored preclinical models of ICI-mediated myocardial toxicities highlight the key role of CD8+ T cells, emphasizing the profound impact of immune checkpoints on maintaining cardiac integrity. Cytokines and macrophages were identified as possible driving factors in disease progression, and at the same time, initial data on possible cardiac antigens responsible are emerging. The implications of contributing factors including thoracic radiation, autoimmune disorder, and the presence of cancer itself are increasingly understood. Besides myocarditis, mouse models unveiled an accelerated progression of atherosclerosis, adding another layer for a thorough understanding of the diverse processes involving cardiovascular immune checkpoint signalling. This review aims to discuss current preclinical models of ICI cardiotoxicity and their potential for improving enhanced risk assessment and diagnostics, offering potential targets for innovative cardioprotective strategies. Lessons from ICI therapy can drive novel approaches in cardiovascular research, extending insights to areas such as myocardial infarction and heart failure.
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Affiliation(s)
- Florian Buehning
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tobias Lerchner
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Julia Vogel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Ulrike B Hendgen-Cotta
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
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13
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Mudra SE, Rayes DL, Agrawal A, Kumar AK, Li JZ, Njus M, McGowan K, Kalam KA, Charalampous C, Schleicher M, Majid M, Syed A, Yesilyaprak A, Klein AL. Immune checkpoint inhibitors and pericardial disease: a systematic review. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:29. [PMID: 38760863 PMCID: PMC11100143 DOI: 10.1186/s40959-024-00234-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION Despite the growing use of immune checkpoint inhibitors (ICI) in cancer treatment, data regarding ICI-associated pericardial disease are primarily derived from case reports and case series. ICI related pericardial disease can be difficult to diagnose and is associated with significant morbidity. We conducted a systematic review to further characterize the epidemiology, clinical presentation, and outcomes of this patient population. METHODS A search of four databases resulted in 31 studies meeting inclusion criteria. Patients > 18 years old who presented with ICI mediated pericardial disease were included. Intervention was medical + surgical therapy and outcomes were development of cardiac tamponade, morbidity, and mortality. RESULTS Thirty- eight patients across 31 cases were included. Patients were majority male (72%) with a median age of 63. Common symptoms included dyspnea (59%) and chest pain (32%), with 41% presenting with cardiac tamponade. Lung cancer (81%) was the most prevalent, and nivolumab (61%) and pembrolizumab (34%) were the most used ICIs. Pericardiocentesis was performed in 68% of patients, and 92% experienced symptom improvement upon ICI cessation. Overall mortality was 16%. DISCUSSION This study provides the most comprehensive analysis of ICI-mediated pericardial disease to date. Patients affected were most commonly male with lung cancer treated with either Nivolumab or Pembrolizumab. Diagnosis may be challenging in the setting of occult presentation with normal EKG and physical exam as well as delayed onset from therapy initiation. ICI-associated pericardial disease demonstrates high morbidity and mortality, as evidenced by a majority of patients requiring pericardiocentesis.
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Affiliation(s)
- Sarah E Mudra
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Danny L Rayes
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Ankit Agrawal
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Ashwin K Kumar
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Jason Z Li
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Meredith Njus
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Kevin McGowan
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Kazi A Kalam
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Charalompos Charalampous
- Department of Internal Medicine, MedStar Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Mary Schleicher
- Floyd D. Loop Memorial Library, Cleveland Clinic, Cleveland, OH, USA
| | - Muhammad Majid
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Alvena Syed
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Abdullah Yesilyaprak
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA.
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14
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Xue G, Li X, Kalim M, Fang J, Jiang Z, Zheng N, Wang Z, Li X, Abdelrahim M, He Z, Nikiforov M, Jin G, Lu Y. Clinical drug screening reveals clofazimine potentiates the efficacy while reducing the toxicity of anti-PD-1 and CTLA-4 immunotherapy. Cancer Cell 2024; 42:780-796.e6. [PMID: 38518774 DOI: 10.1016/j.ccell.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 01/17/2024] [Accepted: 03/01/2024] [Indexed: 03/24/2024]
Abstract
Emerging as the most potent and durable combinational immunotherapy, dual anti-PD-1 and CTLA-4 immune checkpoint blockade (ICB) therapy notoriously increases grade 3-5 immune-related adverse events (irAEs) in patients. Accordingly, attempts to improve the antitumor potency of anti-PD-1+CTLA-4 ICB by including additional therapeutics have been largely discouraged due to concerns of further increasing fatal toxicity. Here, we screened ∼3,000 Food and Drug Administration (FDA)-approved drugs and identified clofazimine as a potential third agent to optimize anti-PD-1+CTLA-4 ICB. Remarkably, clofazimine outperforms ICB dose reduction or steroid treatment in reversing lethality of irAEs, but unlike the detrimental effect of steroids on antitumor efficacy, clofazimine potentiates curative responses in anti-PD-1+CTLA-4 ICB. Mechanistically, clofazimine promotes E2F1 activation in CD8+ T cells to overcome resistance and counteracts pathogenic Th17 cells to abolish irAEs. Collectively, clofazimine potentiates the antitumor efficacy of anti-PD-1+CTLA-4 ICB, curbs intractable irAEs, and may fill a desperate clinical need to improve patient survival.
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Affiliation(s)
- Gang Xue
- Comprehensive Cancer Center, Wake Forest Baptist Health, Winston-Salem, NC 27157, USA.
| | - Xin Li
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Muhammad Kalim
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Jing Fang
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Zhiwu Jiang
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Ningbo Zheng
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Ziyu Wang
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Xiaoyin Li
- Department of Mathematics and Statistics, St. Cloud State University, St Cloud, MN 56301, USA
| | - Maen Abdelrahim
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA
| | - Zhiheng He
- Department of Molecular Microbiology and Immunology, University of Southern California, Los Angeles, CA 90033, USA.
| | | | - Guangxu Jin
- Comprehensive Cancer Center, Wake Forest Baptist Health, Winston-Salem, NC 27157, USA.
| | - Yong Lu
- Houston Methodist Cancer Center/Weill Cornell Medicine, Houston, TX 77030, USA.
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15
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Gao P, Li X, He Z, Zhang H, Zhang Z, Liu Z. Lethal Immune Myocarditis and Myasthenia Gravis Due to Anti-PD-1 Treatment for a Bladder Cancer Patient: A Case Report and Possible Treatment Inspiration. Int Med Case Rep J 2024; 17:359-365. [PMID: 38651079 PMCID: PMC11034559 DOI: 10.2147/imcrj.s449525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/04/2024] [Indexed: 04/25/2024] Open
Abstract
Immune checkpoint inhibitors (ICI) have become a new hope for many patients with advanced cancer by blocking tumor immune escape. Bladder cancer is a common malignant tumor of the urinary tract epithelium that often relapses and metastasizes after surgery, chemotherapy, and radiotherapy. Immunotherapy has dramatically improved patient survival rates and clinical benefits as a new, potentially effective therapy. However, avoidance of various immune-related adverse events (irAEs) remains an implausible idea. ICI-induced myocarditis is different from viral myocarditis, and mortality is still high with the current treatment. We report the case of an 82-year-old female patient with ICI-induced fulminant myocarditis and myasthenia gravis. Although she actively accepted the current mainstream treatment for immune-related myocarditis and myasthenia, she died of heart and respiratory failure. Analyzing and reporting the patient's disease development process and the changes in related indicators may help peers gain a deeper understanding of immune-related adverse events and reduce the mortality of immune-related myocarditis.
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Affiliation(s)
- Pan Gao
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Xinyu Li
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Ziqiu He
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Hongbo Zhang
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Zhi Zhang
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Zonglai Liu
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
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16
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Costanzo V, Ratre YK, Andretta E, Acharya R, Bhaskar LVKS, Verma HK. A Comprehensive Review of Cancer Drug-Induced Cardiotoxicity in Blood Cancer Patients: Current Perspectives and Therapeutic Strategies. Curr Treat Options Oncol 2024; 25:465-495. [PMID: 38372853 DOI: 10.1007/s11864-023-01175-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/20/2024]
Abstract
OPINION STATEMENT Cardiotoxicity has emerged as a serious outcome catalyzed by various therapeutic targets in the field of cancer treatment, which includes chemotherapy, radiation, and targeted therapies. The growing significance of cancer drug-induced cardiotoxicity (CDIC) and radiation-induced cardiotoxicity (CRIC) necessitates immediate attention. This article intricately unveils how cancer treatments cause cardiotoxicity, which is exacerbated by patient-specific risks. In particular, drugs like anthracyclines, alkylating agents, and tyrosine kinase inhibitors pose a risk, along with factors such as hypertension and diabetes. Mechanistic insights into oxidative stress and topoisomerase-II-B inhibition are crucial, while cardiac biomarkers show early damage. Timely intervention and prompt treatment, especially with specific agents like dexrazoxane and beta-blockers, are pivotal in the proactive management of CDIC.
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Affiliation(s)
- Vincenzo Costanzo
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | | | - Emanuela Andretta
- Department of Veterinary Medicine and Animal Productions, University of Naples "Federico II", Naples, Italy
| | - Rakesh Acharya
- Department of Zoology, Guru Ghasidas Vishwavidyalaya, Bilaspur, India
| | - L V K S Bhaskar
- Department of Zoology, Guru Ghasidas Vishwavidyalaya, Bilaspur, India
| | - Henu Kumar Verma
- Department of Immunopathology, Institute of Lungs Health and Immunity, Comprehensive Pneumology Center, Helmholtz Zentrum, Neuherberg, 85764, Munich, Germany.
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17
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Koh YR, Cummings KC. Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations. Anesthesiol Clin 2024; 42:131-143. [PMID: 38278585 DOI: 10.1016/j.anclin.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.
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Affiliation(s)
- Ye Rin Koh
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA
| | - Kenneth C Cummings
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA.
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18
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de Jesus M, Chanda A, Grabauskas T, Kumar M, Kim AS. Cardiovascular disease and lung cancer. Front Oncol 2024; 14:1258991. [PMID: 38410099 PMCID: PMC10896114 DOI: 10.3389/fonc.2024.1258991] [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: 07/14/2023] [Accepted: 01/19/2024] [Indexed: 02/28/2024] Open
Abstract
Lung cancer is the second most common cancer worldwide and the leading cause of cancer-related death. While survival rates have improved with advancements in cancer therapeutics, additional health challenges have surfaced. Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in patients with lung cancer. CVD and lung cancer share many risk factors, such as smoking, hypertension, diabetes, advanced age, and obesity. Optimal management of this patient population requires a full understanding of the potential cardiovascular (CV) complications of lung cancer treatment. This review outlines the common shared risk factors, the spectrum of cardiotoxicities associated with lung cancer therapeutics, and prevention and management of short- and long-term CVD in patients with non-small cell (NSCLC) and small cell (SCLC) lung cancer. Due to the medical complexity of these patients, multidisciplinary collaborative care among oncologists, cardiologists, primary care physicians, and other providers is essential.
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Affiliation(s)
- Mikhail de Jesus
- Department of Cardiology, University of Connecticut Hartford Hospital, Hartford, CT, United States
| | - Anindita Chanda
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, United States
| | - Titas Grabauskas
- University of Connecticut School of Medicine, Farmington, CT, United States
| | - Manish Kumar
- Department of Cardiology, Pat & Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, United States
| | - Agnes S Kim
- Department of Cardiology, Pat & Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, United States
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19
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Jo W, Won T, Daoud A, Čiháková D. Immune checkpoint inhibitors associated cardiovascular immune-related adverse events. Front Immunol 2024; 15:1340373. [PMID: 38375475 PMCID: PMC10875074 DOI: 10.3389/fimmu.2024.1340373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are specialized monoclonal antibodies (mAbs) that target immune checkpoints and their ligands, counteracting cancer cell-induced T-cell suppression. Approved ICIs like cytotoxic T-lymphocyte antigen-4 (CTLA-4), programmed death-1 (PD-1), its ligand PD-L1, and lymphocyte activation gene-3 (LAG-3) have improved cancer patient outcomes by enhancing anti-tumor responses. However, some patients are unresponsive, and others experience immune-related adverse events (irAEs), affecting organs like the lung, liver, intestine, skin and now the cardiovascular system. These cardiac irAEs include conditions like myocarditis, atherosclerosis, pericarditis, arrhythmias, and cardiomyopathy. Ongoing clinical trials investigate promising alternative co-inhibitory receptor targets, including T cell immunoglobulin and mucin domain-containing protein 3 (Tim-3) and T cell immunoreceptor with immunoglobulin and ITIM domain (TIGIT). This review delves into the mechanisms of approved ICIs (CTLA-4, PD-1, PD-L1, and LAG-3) and upcoming options like Tim-3 and TIGIT. It explores the use of ICIs in cancer treatment, supported by both preclinical and clinical data. Additionally, it examines the mechanisms behind cardiac toxic irAEs, focusing on ICI-associated myocarditis and atherosclerosis. These insights are vital as ICIs continue to revolutionize cancer therapy, offering hope to patients, while also necessitating careful monitoring and management of potential side effects, including emerging cardiac complications.
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Affiliation(s)
- Wonyoung Jo
- Department of Biomedical Engineering, Johns Hopkins University, Whiting School of Engineering, Baltimore, MD, United States
| | - Taejoon Won
- Department of Pathobiology, University of Illinois Urbana-Champaign, College of Veterinary Medicine, Urbana, IL, United States
| | - Abdel Daoud
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, United States
| | - Daniela Čiháková
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD, United States
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20
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Li MT, He Y, Huang SY, Hu X, Chen JS. Clinical characteristics, diagnosis and management of nivolumab-induced myocarditis. Invest New Drugs 2024; 42:116-126. [PMID: 38253746 DOI: 10.1007/s10637-024-01421-7] [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: 11/23/2023] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
Nivolumab can cause fatal myocarditis. We aimed to analyze the clinical characteristics of nivolumab-induced myocarditis and provide evidence for clinical diagnosis, treatment, and prevention. Studies involving nivolumab-induced myocarditis were identified in electronic databases from 2000 to 2023 for retrospective analysis. A total of 66 patients were included, with a median age of 68 years. The median onset time of myocarditis is 11.5 days. The main organs affected in persons presented with myocarditis are heart (100.0%) and skeletal muscle (22.7%). The main clinical manifestations are dyspnea (49.2%), fatigue (47.6%), and myalgias (25.4%). The levels of troponin, troponin T, troponin I, creatine kinase, creatine kinase myocardial band, creatine phosphokinase, C-reactive protein, brain natriuretic peptide, and N-terminal brain natriuretic peptide precursor were significantly increased. Histopathology often shows lymphocyte infiltration, myocardial necrosis, and fibrosis. Myocardial immunological parameters usually present positive. Cardiac imaging often suggests complete heart block, intraventricular conduction delay, arrhythmia, myocardial infarction, edema, left ventricular ejection fractions reduction, ventricular dysfunction, and other symptoms of myocarditis. Forty-two (63.6%) patients achieved remission within a median time of 8 days after discontinuation of nivolumab and treatment with systemic corticosteroids, immunoglobulins, plasmapheresis, and immunosuppressant. Thirty-five patients eventually died attributed to myocarditis (68.6%), cancer (20.0%), respiratory failure (5.7%), and other reasons (5.7%). Nivolumab-induced myocarditis should be comprehensively diagnosed based on clinical symptoms, histopathological manifestations, immunological parameters, and cardiac function imaging examinations. Nivolumab should be discontinued immediately, plasmapheresis and systemic corticosteroids combined with immunoglobulins or immunosuppressants may be an effective treatment.
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Affiliation(s)
- Meng-Ting Li
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, 510080, Guangdong Province, China
| | - Yang He
- Department of Pharmacy, The First Hospital of Hunan University of Chinese Medicine, Changsha, 410007, China
| | - Si-Yong Huang
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, 510080, Guangdong Province, China
| | - Xiao Hu
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, 510080, Guangdong Province, China
| | - Ji-Sheng Chen
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, 510080, Guangdong Province, China.
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21
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Haj-Yehia E, Mincu RI, Korste S, Lampe L, Margraf SM, Michel L, Mahabadi AA, Ferdinandy P, Rassaf T, Totzeck M. High neutrophil-to-lymphocyte ratio is associated with cancer therapy-related cardiovascular toxicity in high-risk cancer patients under immune checkpoint inhibitor therapy. Clin Res Cardiol 2024; 113:301-312. [PMID: 37955712 PMCID: PMC10850199 DOI: 10.1007/s00392-023-02327-9] [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: 09/06/2023] [Accepted: 10/17/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Cancer therapy-related cardiovascular toxicity (CTR-CVT) from immune checkpoint inhibitor (ICI) therapy is still incompletely characterized, and patients with pre-existing cardiovascular disease represent a particularly high-risk cohort. Valid parameters for risk stratification of these patients are missing. Neutrophil-to-lymphocyte ratio (NLR) has been shown to predict mortality and adverse events in other cardiovascular cohorts. The present study aims to examine the predictive capacity of NLR for risk stratification of patients particularly vulnerable for CTR-CVT under ICI therapy. METHODS We performed an analysis of 88 cancer patients (69 ± 11 years, 25% female) with pre-existing cardiovascular disease under ICI therapy from the prospective Essen Cardio-Oncology Registry (ECoR). NLR was assessed at patient enrollment and the population was divided through receiver operator characteristic (ROC) curve analysis in patients with low (< 4.57) and high (≥ 4.57) NLR. Endpoint was the whole spectrum of CTR-CVT, according to the European guidelines on cardio-oncology. The median follow-up was 357 days (interquartile range (IQR): 150-509 days). RESULTS We observed 4 cases of myocarditis, 17 cases of vascular toxicity, 3 cases of arterial hypertension, 22 cases of arrhythmia or QTc prolongation and 17 cases of cardiovascular dysfunction. NLR was associated with overall CTR-CVT by univariable Cox regression (hazard ratio (HR): 1.443; 95% confidence interval (CI) 1.082-1.925; p = 0.013). However, this association was attenuated after adjusting for further confounders. CONCLUSION NLR is moderately associated with CTR-CVT in cancer patients with pre-existing cardiovascular disease under ICI therapy. Surveillance of NLR during ICI therapy might be an effective and economically biomarker for risk stratification in these high-risk patients.
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Affiliation(s)
- Elias Haj-Yehia
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Raluca I Mincu
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Sebastian Korste
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Lena Lampe
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Simone M Margraf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Amir A Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany.
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22
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Shalata W, Steckbeck R, Abu Salman A, Abu Saleh O, Abu Jama A, Attal ZG, Shalata S, Alnsasra H, Yakobson A. Perimyocarditis Associated with Immune Checkpoint Inhibitors: A Case Report and Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:224. [PMID: 38399513 PMCID: PMC10890382 DOI: 10.3390/medicina60020224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Patient prognoses have been significantly enhanced by immune checkpoint inhibitors (ICIs), altering the standard of care in cancer treatment. These novel antibodies have become a mainstay of care for metastatic non-small-cell lung cancer (mNSCLC) patients. Several types of adverse events related to ICIs have been identified and documented as a result of the launch of these innovative medicines. We present here a 74-year-old female patient with a stage IV lung adenocarcinoma, treated with nivolumab plus ipilimumab, who developed perimyocarditis two weeks after receiving the third cycle of immune checkpoint inhibitor therapy. The patient was diagnosed using troponin levels, computed tomography (CT) angiography, and echocardiography. After hospitalization, her cardiac condition was successfully resolved with corticosteroids, colchicine, and symptomatic treatment. To the best of our knowledge, this is one of the rarest cases to be reported of perimyocarditis as a toxicity of immunotherapy in a patient treated for adenocarcinoma of the lung.
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Affiliation(s)
- Walid Shalata
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Rachel Steckbeck
- Medical School for International Health and Sciences, Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Amjad Abu Salman
- Cardiology Department, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Omar Abu Saleh
- Department of Dermatology and Venereology, Emek Medical Centre, Afula 18341, Israel
| | - Ashraf Abu Jama
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Zoé Gabrielle Attal
- Medical School for International Health and Sciences, Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Sondos Shalata
- Nutrition Unit, Galilee Medical Center, Nahariya 22000, Israel
| | - Hilmi Alnsasra
- Cardiology Department, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
| | - Alexander Yakobson
- The Legacy Heritage Oncology Center and Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva 84105, Israel
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23
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Upadhya B, Hegde S, Tannu M, Stacey RB, Kalogeropoulos A, Schocken DD. Preventing new-onset heart failure: Intervening at stage A. Am J Prev Cardiol 2023; 16:100609. [PMID: 37876857 PMCID: PMC10590769 DOI: 10.1016/j.ajpc.2023.100609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/24/2023] [Accepted: 09/30/2023] [Indexed: 10/26/2023] Open
Abstract
Heart failure (HF) prevention is an urgent public health need with national and global implications. Stage A HF patients do not show HF symptoms or structural heart disease but are at risk of HF development. There are no unique recommendations on detecting Stage A patients. Patients in Stage A are heterogeneous; many patients have different combinations of risk factors and, therefore, have markedly different absolute risks for HF. Comprehensive strategies to prevent HF at Stage A include intensive blood pressure lowering, adequate glycemic and lipid management, and heart-healthy behaviors (adopting Life's Essential 8). First and foremost, it is imperative to improve public awareness of HF risk factors and implement healthy lifestyle choices very early. In addition, recognize the HF risk-enhancing factors, which are nontraditional cardiovascular (CV) risk factors that identify individuals at high risk for HF (genetic susceptibility for HF, atrial fibrillation, chronic kidney disease, chronic liver disease, chronic inflammatory disease, sleep-disordered breathing, adverse pregnancy outcomes, radiation therapy, a history of cardiotoxic chemotherapy exposure, and COVID-19). Early use of biomarkers, imaging markers, and echocardiography (noninvasive measures of subclinical systolic and diastolic dysfunction) may enhance risk prediction among individuals without established CV disease and prevent chemotherapy-induced cardiomyopathy. Efforts are needed to address social determinants of HF risk for primordial HF prevention.Central illustrationPolicies developed by organizations such as the American Heart Association, American College of Cardiology, and the American Diabetes Association to reduce CV disease events must go beyond secondary prevention and encompass primordial and primary prevention.
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Affiliation(s)
- Bharathi Upadhya
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Manasi Tannu
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - R. Brandon Stacey
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andreas Kalogeropoulos
- Division of Cardiology, Department of Medicine, Stony Brook University School of Medicine, Long Island, NY, USA
| | - Douglas D. Schocken
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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24
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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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25
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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: 1] [Impact Index Per Article: 1.0] [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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26
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Luo Y, Zeng Z, Liu Y, Liu A. Reflecting on the cardiac toxicity in non-small cell lung cancer in the era of immune checkpoint inhibitors therapy combined with thoracic radiotherapy. Biochim Biophys Acta Rev Cancer 2023; 1878:189008. [PMID: 37913939 DOI: 10.1016/j.bbcan.2023.189008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/31/2023] [Accepted: 10/16/2023] [Indexed: 11/03/2023]
Abstract
In recent years, immune checkpoint inhibitors (ICIs) have become a widely used treatment for non-small cell lung cancer (NSCLC), and the combination with traditional radiotherapy (RT) has shown significant potential in prolonging patient survival. However, both thoracic RT and ICIs can lead to cardiac toxicity, including radiation-induced heart damage (RIHD) and immunotherapy-related heart damage (IRHD). It still remains uncertain whether the combination of thoracic RT and immunotherapy will exacerbate acute or late cardiovascular (CV) toxicity and incidence. In this review, we summarize safety data from relevant clinical studies regarding CV toxicity for the combination therapy in NSCLC patients, explore the underlying synergetic mechanisms and common risk factors, and proposed treatment and management strategies. We hope to increase emphasis on the long-term assessment of CV toxicity risks associated with the combination therapy, and reduce the incidence of CV deaths resulting from such regimens.
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Affiliation(s)
- Yuxi Luo
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province 330006, China; Jiangxi Key Laboratory of Clinical Translational Cancer Research, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province 330006, China; Radiation Induced Heart Damage Institute of Nanchang University, Nanchang, Jiangxi Province 330006, China
| | - Zhimin Zeng
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province 330006, China; Jiangxi Key Laboratory of Clinical Translational Cancer Research, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province 330006, China; Radiation Induced Heart Damage Institute of Nanchang University, Nanchang, Jiangxi Province 330006, China
| | - Yunwei Liu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province 330006, China; Jiangxi Key Laboratory of Clinical Translational Cancer Research, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province 330006, China; Radiation Induced Heart Damage Institute of Nanchang University, Nanchang, Jiangxi Province 330006, China
| | - Anwen Liu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province 330006, China; Jiangxi Key Laboratory of Clinical Translational Cancer Research, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province 330006, China; Radiation Induced Heart Damage Institute of Nanchang University, Nanchang, Jiangxi Province 330006, China.
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27
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Kersting D, Mavroeidi IA, Settelmeier S, Seifert R, Schuler M, Herrmann K, Rassaf T, Rischpler C. Molecular Imaging Biomarkers in Cardiooncology: A View on Established Technologies and Future Perspectives. J Nucl Med 2023; 64:29S-38S. [PMID: 37918843 DOI: 10.2967/jnumed.122.264868] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 09/05/2023] [Indexed: 11/04/2023] Open
Abstract
Novel therapeutic options have significantly improved survival and long-term outcomes in many cancer entities. Unfortunately, this improvement in outcome is often accompanied by new and increasingly relevant therapy-related cardiovascular toxicity. In this context, cardiooncology has emerged as a new field of interdisciplinary individual patient care. Important tasks are pretherapeutic risk stratification and early detection and treatment of cardiotoxicity, which comprises cardiac damage in relation to cardiovascular comorbidities, the tumor disease, and cancer treatment. Clinical manifestations can cover a broad spectrum, ranging from subtle and usually asymptomatic abnormalities to serious acute or chronic complications. Typical manifestations include acute and chronic heart failure, myo- and pericarditis, arrythmias, ischemia, and endothelial damage. They can be related to almost all current cancer treatments, including cytotoxic chemotherapy, targeted therapy, immunotherapy, hormonal therapy, and radiotherapy. Molecular imaging biomarkers can aid in pretherapeutic cardiooncologic assessment for primary prevention and personalized surveillance, detection, and differential diagnosis of cardiotoxic complications. Potential advantages over conventional diagnostics are the higher detection sensitivity for subtle changes in cardiac homeostasis, higher reproducibility, and better observer independence. Hybrid imaging with highly sensitive PET/MRI may be particularly suited for early diagnosis. Important technologies that are encouraged in current multidisciplinary guidelines are equilibrium radionuclide angiography for evaluation of ventricular function and chamber morphology, as well as myocardial perfusion imaging for additional detection of ischemia. Novel modalities that may detect even earlier signs of cardiotoxicity comprise 123I-metaiodobenzylguanidine SPECT to visualize sympathetic innervation, 18F-FDG and somatostatin receptor (68Ga-DOTATOC/DOTATATE) PET to indicate a metabolic shift and inflammation, and 68Ga-fibroblast activation protein inhibitor PET to monitor cardiac remodeling. In addition, PET imaging of mitochondrial function has recently been introduced in preclinical models and will potentially broaden the field of application through higher sensitivity and specificity and by enabling higher individualization of diagnostic concepts.
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Affiliation(s)
- David Kersting
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany;
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Ilektra-Antonia Mavroeidi
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; and
| | - Stephan Settelmeier
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Robert Seifert
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Martin Schuler
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; and
| | - Ken Herrmann
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christoph Rischpler
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
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28
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Mitsuboshi S, Hamano H, Niimura T, Ozaki AF, Patel PM, Lin TJ, Tanaka Y, Kimura I, Iwata N, Shiromizu S, Chuma M, Koyama T, Yamanishi Y, Kanda Y, Ishizawa K, Zamami Y. Association between immune checkpoint inhibitor-induced myocarditis and concomitant use of thiazide diuretics. Int J Cancer 2023; 153:1472-1476. [PMID: 37306521 DOI: 10.1002/ijc.34616] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/04/2023] [Accepted: 05/15/2023] [Indexed: 06/13/2023]
Abstract
Although an association has been reported between diuretics and myocarditis, it is unclear whether the risk of immune checkpoint inhibitor (ICI)-induced myocarditis is affected by concomitant diuretics. Thus, the aim of this work was to evaluate the impact of concomitant diuretics on ICI-induced myocarditis. This cross-sectional study used disproportionality analysis and a pharmacovigilance database to assess the risk of myocarditis with various diuretics in patients receiving ICIs via the analysis of data entered into the VigiBase database through December 2022. Multiple logistic regression analysis was performed to identify risk factors for myocarditis in patients who received ICIs. A total of 90 611 patients who received ICIs, including 975 cases of myocarditis, were included as the eligible dataset. A disproportionality in myocarditis was observed for loop diuretic use (reporting odds ratio 1.47, 95% confidence interval [CI] 1.02-2.04, P = .03) and thiazide use (reporting odds ratio 1.76, 95% CI 1.20-2.50, P < .01) in patients who received ICIs. The results of the multiple logistic regression analysis showed that the use of thiazides (odds ratio 1.67, 95% CI 1.15-2.34, P < .01) was associated with an increased risk of myocarditis in patients who received ICIs. Our findings may help to predict the risk of myocarditis in patients receiving ICIs.
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Affiliation(s)
| | - Hirofumi Hamano
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Takahiro Niimura
- Clinical Trial Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Aya F Ozaki
- Department of Clinical Pharmacy Practice, University of California, Irvine, California, USA
| | - Pranav M Patel
- Department of Cardiology, School of Medicine, University of California, Irvine, California, USA
| | - Tsung-Jen Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yuta Tanaka
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Ikuya Kimura
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Naohiro Iwata
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Shoya Shiromizu
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Masayuki Chuma
- Department of Hospital Pharmacy and Pharmacology, Asahikawa Medical University, Asahikawa, Japan
| | - Toshihiro Koyama
- Department of Pharmaceutical Biomedicine, Okayama University, Okayama, Japan
| | - Yoshihiro Yamanishi
- Department of Complex Systems Science, Graduate School of Informatics Nagoya University, Nagoya, Japan
| | - Yasunari Kanda
- Division of Pharmacology, National Institute of Health Sciences, Kawasaki, Japan
| | - Keisuke Ishizawa
- Clinical Trial Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yoshito Zamami
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
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Liu X, Zeng Z, Cao J, Li X, Muhetaer M, Jin Z, Cai H, Lu Z. Sintilimab-Induced Myocarditis in a Patient with Gastric Cancer: A Case Report and Literature Review. J Cardiovasc Dev Dis 2023; 10:422. [PMID: 37887869 PMCID: PMC10607029 DOI: 10.3390/jcdd10100422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/15/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as a powerful and efficacious therapeutic approach for many cancer patients. Sintilimab is a fully human IgG4 monoclonal antibody that binds with programmed cell death receptor-1 (PD-1) to block its interaction with ligands, thereby enhancing the antitumor effects of T cells. However, ICIs may induce immune-related adverse events (irAEs) in various systems and organs, with fulminant myocarditis being the most severe one. We report the case of a 45-year-old female with gastric cancer who developed chest pain two weeks after chemotherapy with sintilimab; she was diagnosed with immune-associated fulminant myocarditis and experienced an Adams-Stokes syndrome attack in the hospital. Eventually, she was discharged after being treated with methylprednisolone, immunoglobulin, and an IABP.
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Affiliation(s)
- Xin Liu
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Ziyue Zeng
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Jianlei Cao
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Xianqing Li
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Muheremu Muhetaer
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Zhili Jin
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Huanhuan Cai
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Zhibing Lu
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
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Jeyalan V, Austin D, Loh SX, Wangsaputra VK, Spyridopoulos I. Fractalkine/CX 3CR1 in Dilated Cardiomyopathy: A Potential Future Target for Immunomodulatory Therapy? Cells 2023; 12:2377. [PMID: 37830591 PMCID: PMC10571889 DOI: 10.3390/cells12192377] [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: 08/25/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/14/2023] Open
Abstract
Dilated cardiomyopathy (DCM) is a cardiac condition with structural and functional impairment, where either the left ventricle or both ventricular chambers are enlarged, coinciding with reduced systolic pump function (reduced ejection fraction, rEF). The prevalence of DCM is more than 1:250 individuals, and mortality largely due to heart failure in two-third of cases, and sudden cardiac death in one-third of patients. Damage to the myocardium, whether from a genetic or environmental cause such as viruses, triggers inflammation and recruits immune cells to the heart to repair the myocardium. Examination of myocardial biopsy tissue often reveals an inflammatory cell infiltrate, T lymphocyte (T cell) infiltration, or other activated immune cells. Despite medical therapy, adverse outcomes for DCM remain. The evidence base and existing literature suggest that upregulation of CX3CR1, migration of immune cells, together with cytomegalovirus (CMV) seropositivity is associated with worse outcomes in patients with dilated cardiomyopathy. We hypothesise that this potentially occurs through cardiac inflammation and fibrosis, resulting in adverse remodelling. Immune modulators to target this pathway may potentially improve outcomes above and beyond current guideline-recommended therapy.
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Affiliation(s)
- Visvesh Jeyalan
- Academic Cardiovascular Unit, The James Cook University Hospital, Middlesbrough TS4 3BW, UK; (V.J.); (D.A.)
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK;
| | - David Austin
- Academic Cardiovascular Unit, The James Cook University Hospital, Middlesbrough TS4 3BW, UK; (V.J.); (D.A.)
- Population Health Science Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Shu Xian Loh
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK;
| | - Vincent Kharisma Wangsaputra
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK;
- Faculty of Medicine, Universitas Indonesia, Central Jakarta 10430, Indonesia
| | - Ioakim Spyridopoulos
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK;
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK;
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He Y, Chen W, Cai J, Luo C, Zhou C, Wei L. PD-1 inhibitors-associated myocarditis in non-small cell lung cancer patients. J Thorac Dis 2023; 15:4606-4619. [PMID: 37868865 PMCID: PMC10586979 DOI: 10.21037/jtd-23-596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 07/21/2023] [Indexed: 10/24/2023]
Abstract
Background Immune checkpoint inhibitors (ICIs)-associated myocarditis remains a rare but fatal adverse event. The authors sought to provide a comprehensive clinical description of ICI-associated myocarditis by analyzing symptoms, laboratory indicators, imaging features, and management of ICI-associated myocarditis in patients with non-small cell lung cancer (NSCLC). Methods A retrospective study was conducted to analyze 14 ICI-associated myocarditis cases and 45 control patients to clarify clinical features of ICI-associated myocarditis. Detailed laboratory tests and imaging examinations were performed in 14 cases, and the rescue process and follow-up after the onset of myocarditis were recorded. Results A total of 14 (2.08%) NSCLC patients developed ICI-related myocarditis, with a median time of onset of 34 days (interquartile range, 12 to 146 days) after ICI initiation. The most common concurrent adverse events in cases were myositis (P<0.001) and peripheral neuritis (P<0.001). Among cases, cardiac troponin I (cTnI) levels were abnormally elevated in 92% of patients, and electrocardiogram (ECG) showed abnormal in all cases. Steroid therapy was used in 92.9% of patients with ICI-associated myocarditis, of which the response rate to steroids was 76.9% and the mortality rate was 7.1%. A dose of 1 g/d of glucocorticoid supplemented by immunoglobulin was observed to be effective for severe myocarditis. Conclusions Early identification and treatment are essential for managing myocarditis caused by ICI. Routine monitoring of cTnI level and ECG is most sensitive for the early diagnosis of ICI-related myocarditis. High-dose of glucocorticoids can effectively relieve the symptoms of ICI-associated myocarditis and stabilize the condition, especially for fulminant myocarditis.
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Affiliation(s)
- Yuwen He
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wanwen Chen
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Junying Cai
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Caiyin Luo
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chengzhi Zhou
- State Key Laboratory of Respiratory Disease, National Clinical Research Centre for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li Wei
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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32
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Gusev A. Germline mechanisms of immunotherapy toxicities in the era of genome-wide association studies. Immunol Rev 2023; 318:138-156. [PMID: 37515388 PMCID: PMC11472697 DOI: 10.1111/imr.13253] [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: 03/14/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023]
Abstract
Cancer immunotherapy has revolutionized the treatment of advanced cancers and is quickly becoming an option for early-stage disease. By reactivating the host immune system, immunotherapy harnesses patients' innate defenses to eradicate the tumor. By putatively similar mechanisms, immunotherapy can also substantially increase the risk of toxicities or immune-related adverse events (irAEs). Severe irAEs can lead to hospitalization, treatment discontinuation, lifelong immune complications, or even death. Many irAEs present with similar symptoms to heritable autoimmune diseases, suggesting that germline genetics may contribute to their onset. Recently, genome-wide association studies (GWAS) of irAEs have identified common germline associations and putative mechanisms, lending support to this hypothesis. A wide range of well-established GWAS methods can potentially be harnessed to understand the etiology of irAEs specifically and immunotherapy outcomes broadly. This review summarizes current findings regarding germline effects on immunotherapy outcomes and discusses opportunities and challenges for leveraging germline genetics to understand, predict, and treat irAEs.
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Affiliation(s)
- Alexander Gusev
- Division of Population Sciences, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
- Division of Genetics, Brigham & Women's Hospital, Boston, Massachusetts, USA
- The Broad Institute, Cambridge, Massachusetts, USA
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Chitsazan M, Amin A, Ladel L, Baig A, Chitsazan M. Cardiovascular Toxicity Associated With Immune Checkpoint Inhibitor Therapy: A Comprehensive Review. Crit Pathw Cardiol 2023; 22:69-82. [PMID: 37363862 DOI: 10.1097/hpc.0000000000000327] [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: 06/28/2023]
Abstract
Immune checkpoint inhibitors (ICIs), a significant breakthrough treatment of cancer, exert their function through enhancing the immune system's ability to recognize and attack cancer cells. However, these revolutionary cancer treatments have been associated with a range of immune-related adverse effects, including cardiovascular toxicity. The most commonly reported cardiovascular toxicities associated with ICIs are myocarditis, pericarditis, arrhythmias, and vasculitis. These cardiovascular manifestations are often severe and can lead to life-threatening complications. Therefore, prompt identification and management of these toxicities is critical, and a multidisciplinary teamwork by cardiologists and oncologists are required to ensure optimal patient outcomes. In this review, we summarize the current knowledge on the mechanisms underlying ICI-associated cardiovascular toxicity, clinical presentations of these toxicities, potential risk factors, diagnosis, management, and surveillance strategies during ICI therapy. While ICIs have already transformed cancer treatment, further research is needed to better understand and manage their immune-related cardiovascular effects, and possibly, to identify biomarkers which can predict the occurrence of these cardiovascular complications.
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Affiliation(s)
| | - Ahmad Amin
- Medstar Union Memorial Hospital, Baltimore, MD
| | - Luisa Ladel
- From the Department of Medicine, Norwalk Hospital, Norwalk, CT
| | - Alyza Baig
- From the Department of Medicine, Norwalk Hospital, Norwalk, CT
| | - Mitra Chitsazan
- Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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34
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Rihackova E, Rihacek M, Vyskocilova M, Valik D, Elbl L. Revisiting treatment-related cardiotoxicity in patients with malignant lymphoma-a review and prospects for the future. Front Cardiovasc Med 2023; 10:1243531. [PMID: 37711551 PMCID: PMC10499183 DOI: 10.3389/fcvm.2023.1243531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
Treatment of malignant lymphoma has for years been represented by many cardiotoxic agents especially anthracyclines, cyclophosphamide, and thoracic irradiation. Although they are in clinical practice for decades, the precise mechanism of cardiotoxicity and effective prevention is still part of the research. At this article we discuss most routinely used anti-cancer drugs in chemotherapeutic regiments for malignant lymphoma with the focus on novel insight on molecular mechanisms of cardiotoxicity. Understanding toxicity at molecular levels may unveil possible targets of cardioprotective supportive therapy or optimization of current therapeutic protocols. Additionally, we review novel specific targeted therapy and its challenges in cardio-oncology.
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Affiliation(s)
- Eva Rihackova
- Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine of Masaryk University, Brno, Czech Republic
| | - Michal Rihacek
- Department of Laboratory Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Maria Vyskocilova
- Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine of Masaryk University, Brno, Czech Republic
| | - Dalibor Valik
- Department of Laboratory Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lubomir Elbl
- Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine of Masaryk University, Brno, Czech Republic
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35
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Reichert C, Baldini C, Mezghani S, Maubec E, Longvert C, Mortier L, Quereux G, Jannic A, Machet L, de Quatrebarbes J, Nardin C, Beneton N, Amini Adle M, Funck-Brentano E, Descamps V, Hachon L, Malissen N, Baroudjian B, Brunet-Possenti F. Combined Nivolumab and Ipilimumab in Octogenarian and Nonagenarian Melanoma Patients. Cancers (Basel) 2023; 15:4330. [PMID: 37686606 PMCID: PMC10486537 DOI: 10.3390/cancers15174330] [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: 07/16/2023] [Revised: 08/13/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Data regarding elderly melanoma patients treated with anti-PD-1 or anti-CTLA-4 antibodies are in favor of tolerability outcomes that are similar to those of younger counterparts. However, there are very few studies focusing on elderly patients receiving nivolumab combined with ipilimumab (NIVO + IPI). Here, we ask what are the current prescribing patterns of NIVO + IPI in the very elderly population and analyze the tolerance profile. This French multicenter retrospective study was conducted on 60 melanoma patients aged 80 years and older treated with NIVO + IPI between January 2011 and June 2022. The mean age at first NIVO + IPI administration was 83.7 years (range: 79.3-93.3 years). Fifty-five patients (92%) were in good general condition and lived at home. Two dosing regimens were used: NIVO 1 mg/kg + IPI 3 mg/kg Q3W (NIVO1 + IPI3) in 27 patients (45%) and NIVO 3 mg/kg + IPI 1 mg/kg Q3W (NIVO3 + IPI1) in 33 patients (55%). NIVO + IPI was a first-line treatment in 39 patients (65%). The global prevalence of immune-related adverse events was 63% (38/60), with 27% (16/60) being of grade 3 or higher. Grade ≥ 3 adverse events were less frequent in patients treated with NIVO3 + IPI1 compared with those treated with NIVO1 + IPI3 (12% versus 44%, p = 0.04). In conclusion, the prescribing patterns of NIVO + IPI in very elderly patients are heterogeneous in terms of the dosing regimen and line of treatment. The safety profile of NIVO + IPI is reassuring; whether or not the low-dose regimen NIVO3 + IPI1 should be preferred over NIVO1 + IPI3 in patients aged 80 years or older remains an open question.
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Affiliation(s)
- Constance Reichert
- Department of Dermatology, Hôpital Bichat AP-HP, Université Paris Cité, 75018 Paris, France; (C.R.); (V.D.)
| | - Capucine Baldini
- Drug Development Department, Institut Gustave Roussy, CNRS-UMS 3655 and INSERM US23, 94805 Villejuif, France;
| | - Sarah Mezghani
- Department of Imaging, Institut Curie, PSL Research University, 75005 Paris, France;
| | - Eve Maubec
- Department of Dermatology, Hôpital Avicenne AP-HP, Université Sorbonne Paris Nord—Campus de Bobigny, 93000 Bobigny, France;
| | - Christine Longvert
- Department of Dermatology, EA4340-BECCOH, Hôpital Ambroise Paré APHP, Université Paris-Saclay, 92100 Boulogne-Billancourt, France; (C.L.); (E.F.-B.)
| | - Laurent Mortier
- Department of Dermatology, Claude Huriez Hospital, Lille University, Inserm U1189, 59000 Lille, France;
| | - Gaëlle Quereux
- Department of Dermatology, Centre Hospitalier Universitaire de Nantes, CIC 1413, INSERM, Immunology and New Concepts in ImmunoTherapy, INCIT, UMR 1302, Nantes University, 44000 Nantes, France;
| | - Arnaud Jannic
- Dermatology Department, Hôpital Henri Mondor AP-HP, 94000 Créteil, France;
| | - Laurent Machet
- Department of Dermatology, Tours University Hospital, 37000 Tours, France;
| | - Julie de Quatrebarbes
- Department of Dermatology, Centre Hospitalier Annecy-Genevois, 74370 Annecy, France;
| | - Charlée Nardin
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, 25000 Besançon, France;
| | - Nathalie Beneton
- Department of Dermatology, Centre Hospitalier du Mans, 72037 Le Mans, France;
| | - Mona Amini Adle
- Oncodermatology Department Centre Léon Bérard, 69008 Lyon, France;
| | - Elisa Funck-Brentano
- Department of Dermatology, EA4340-BECCOH, Hôpital Ambroise Paré APHP, Université Paris-Saclay, 92100 Boulogne-Billancourt, France; (C.L.); (E.F.-B.)
| | - Vincent Descamps
- Department of Dermatology, Hôpital Bichat AP-HP, Université Paris Cité, 75018 Paris, France; (C.R.); (V.D.)
| | - Lorry Hachon
- Department of Pharmacy, Hôpital Bichat, AP-HP, 75018 Paris, France;
| | - Nausicaa Malissen
- Dermatology and Skin Cancer Department, APHM, CRCM Inserm U1068, CNRS U7258, CHU Timone, Aix Marseille University, 13007 Marseille, France;
| | - Barouyr Baroudjian
- Department of Dermato-Oncology, Hôpital Saint-Louis AP-HP, Inserm U976, Université Paris Cité, 75010 Paris, France;
| | - Florence Brunet-Possenti
- Department of Dermatology, Hôpital Bichat AP-HP, Université Paris Cité, 75018 Paris, France; (C.R.); (V.D.)
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Diaz-Rodriguez PE, Muns-Aponte CM, Velazquez-Acevedo SI, Ortiz-Malave CM, Acevedo J, Merced-Ortiz FG. An Uncommon Case of Myocarditis Secondary to Durvalumab Plus Tremelimumab. Cureus 2023; 15:e43628. [PMID: 37719633 PMCID: PMC10504866 DOI: 10.7759/cureus.43628] [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: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Tumor immunotherapy is an important clinical strategy for the treatment of various solid and hematological malignancies, and its use is on the rise. Immune checkpoint inhibitors (ICIs) are immunotherapies that boost anticancer immune responses by targeting receptors on the surface of T-lymphocytes. Two important ICIs are anti-programmed death ligand-1 (anti-PD-L1) monoclonal antibodies and anti-cytotoxic T-lymphocyte-associated antigen-4 (anti-CTLA-4) monoclonal antibodies. Tremelimumab (anti-CTLA-4) and durvalumab (anti-PD-L1) have been shown to be effective monotherapies. However, their combination has demonstrated effective and encouraging antitumor activity with manageable safety in patients with unresectable hepatocellular carcinoma. We present the case of an 80-year-old male with hepatocellular carcinoma who had undergone drug-eluting bead transarterial chemoembolization (DEB-TACE) on three occasions and had been started on a combination of ICIs, durvalumab, and tremelimumab. He subsequently developed various immune-related adverse effects in different organ systems, including hepatic and cardiovascular complications. Appropriate treatment was administered, but ultimately, he passed away. We aim to discuss the initial evaluation for suspected immune-related adverse events, specifically those related to myocarditis and its various manifestations, prognosis, and treatment.
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Affiliation(s)
| | | | | | | | - Jose Acevedo
- Internal Medicine, Veterans Affairs Caribbean Healthcare System, San Juan, PRI
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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: 4] [Impact Index Per Article: 4.0] [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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Turker I, Johnson DB. Immune checkpoint inhibitor-related myocarditis: current understanding and potential diagnostic and therapeutic strategies. Expert Opin Drug Saf 2023; 22:909-919. [PMID: 37647330 PMCID: PMC10530188 DOI: 10.1080/14740338.2023.2254218] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/31/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Myocarditis associated with immune checkpoint inhibitors presents with an often-severe clinical phenotype with arrhythmias and concurrent myositis. This condition tends to occur early after treatment onset and is associated with a high fatality rate. Diagnosis may be challenging, and treatment algorithms are still evolving. AREAS COVERED This review will provide an overview of immune checkpoint inhibitor mechanism of action and how it relates to myocarditis pathophysiology, diagnostic algorithms and potential pitfalls, and emerging treatment approaches published until May 2023. We will focus on the state of the field and potential new directions in research and patient care. We will also provide consensus-based diagnostic and therapeutic algorithms endorsed by major societies. EXPERT OPINION The field needs more evidence-based approaches to risk stratification so that therapy can be tailored toward less cardiotoxic alternatives in high-risk patients. For diagnostic and therapeutic approaches, data from animal models are unlikely to provide conclusive evidence given the complexity of the human immune system. We strongly invite practitioners in the field to contribute every case to the ongoing multicenter registries.
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Affiliation(s)
- Isik Turker
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, Missouri, MO, USA
| | - Douglas B. Johnson
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, TN, USA
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Moradi A, Kodali A, Okoye C, Klein DH, Mohamoud I, Olanisa OO, Parab P, Chaudhary P, Mukhtar S, Mohammed L. A Systematic Review of Myocarditis Induced by Immune Checkpoint Inhibitors: How Concerning Is the Most Common Cardiotoxicity of Immune Checkpoint Inhibitors? Cureus 2023; 15:e42071. [PMID: 37602125 PMCID: PMC10434730 DOI: 10.7759/cureus.42071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Novel cancer therapies have revolutionized the management of various cancers. An immune checkpoint inhibitor (ICI) is one of these antitumor medications. ICIs, which are immune therapies, enhance the immune system's capacity to fight cancer cells. Based on the receptors that they inhibit, such as PD-1, PD-L1, and CTLA-4, ICIs are subdivided. Although this class of drugs is extremely beneficial for cancer patients, their adverse effects can be fatal. Multiple organs, such as the cardiovascular system, may be impacted by immune-related adverse effects (irAEs). These cardiotoxic irAEs can occur at a rate of up to 1% and can be fatal. Myocarditis is the most prevalent of all cardiotoxicities. The purpose of this systematic review is to assess the seriousness of myocarditis, the most prevalent cardiotoxicity of ICIs, and the importance of screening. We chose studies based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria. Therefore, from 2018 to 2023, we gathered articles from databases such as PubMed, ScienceDirect, Web of Science, the Cochrane Library, and Google Scholar. Of the 665 studies identified based on various screening methods and quality assessment tools, 13 were selected for inclusion in the study. This study shows that although the risk of myocarditis in ICI therapy is low and the majority of cases are asymptomatic or mild, some cases can be deadly and disastrous, and physicians should be aware that if myocarditis is suspected based on clinical symptoms, troponin, electrocardiogram, and echocardiogram, treatment should be initiated accordingly.
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Affiliation(s)
- Ali Moradi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Athri Kodali
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Chiugo Okoye
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Dhadon Hannah Klein
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Iman Mohamoud
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Olawale O Olanisa
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Panah Parab
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Priti Chaudhary
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sonia Mukhtar
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Giovannini E, Bonasoni MP, D'Aleo M, Tamagnini I, Tudini M, Fais P, Pelotti S. Pembrolizumab-Induced Fatal Myasthenia, Myocarditis, and Myositis in a Patient with Metastatic Melanoma: Autopsy, Histological, and Immunohistochemical Findings-A Case Report and Literature Review. Int J Mol Sci 2023; 24:10919. [PMID: 37446095 DOI: 10.3390/ijms241310919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) represent a major advance in cancer treatment. The lowered immune tolerance induced by ICIs brought to light a series of immune-related adverse events (irAEs). Pembrolizumab belongs to the ICI class and is a humanized IgG4 anti-PD-1 antibody that blocks the interaction between PD-1 and PD-L1. The ICI-related irAEs involving various organ systems and myocarditis are uncommon (incidence of 0.04% to 1.14%), but they are associated with a high reported mortality. Unlike idiopathic inflammatory myositis, ICI-related myositis has been reported to frequently co-occur with myocarditis. The triad of myasthenia, myositis, and myocarditis must not be underestimated as they can rapidly deteriorate, leading to death. Herein we report a case of a patient with metastatic melanoma who fatally developed myasthenia gravis, myocarditis, and myositis, after a single cycle of pembrolizumab. Considering evidence from the literature review, autopsy, histological, and immunohistochemical investigations on heart and skeletal muscle are presented and discussed, also from a medical-legal perspective.
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Affiliation(s)
- Elena Giovannini
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Maria Paola Bonasoni
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Michele D'Aleo
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Ione Tamagnini
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Matteo Tudini
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Paolo Fais
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Susi Pelotti
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
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Chen M, Xue J, Wang M, Yang J, Chen T. Cardiovascular Complications of Pan-Cancer Therapies: The Need for Cardio-Oncology. Cancers (Basel) 2023; 15:cancers15113055. [PMID: 37297017 DOI: 10.3390/cancers15113055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/28/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
It is more likely that a long-term survivor will have both cardiovascular disease and cancer on account of the progress in cancer therapy. Cardiotoxicity is a well-recognized and highly concerning adverse effect of cancer therapies. This side effect can manifest in a proportion of cancer patients and may lead to the discontinuation of potentially life-saving anticancer treatment regimens. Consequently, this discontinuation may adversely affect the patient's survival prognosis. There are various underlying mechanisms by which each anticancer treatment affects the cardiovascular system. Similarly, the incidence of cardiovascular events varies with different protocols for malignant tumors. In the future, comprehensive cardiovascular risk assessment and clinical monitoring should be considered for cancer treatments. Baseline cardiovascular evaluation risk should be emphasized prior to initiating clinical therapy in patients. Additionally, we highlight that there is a need for cardio-oncology to avoid or prevent cardiovascular side effects. Cardio-oncology service is based on identifying cardiotoxicity, developing strategies to reduce these toxicities, and minimizing long-term cardiotoxic effects.
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Affiliation(s)
- Mengjia Chen
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Jianing Xue
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Maoling Wang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Junyao Yang
- Department of Laboratory Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Ting Chen
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
- Alibaba-Zhejiang University Joint Research Center of Future Digital Healthcare, Hangzhou 310058, China
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Delombaerde D, De Sutter J, Croes L, Vervloet D, Moerman V, Van de Veire N, Willems AM, Wouters K, Peeters M, Prenen H, Vulsteke C. Extensive CArdioVAscular Characterization and Follow-Up of Patients Receiving Immune Checkpoint Inhibitors: A Prospective Multicenter Study. Pharmaceuticals (Basel) 2023; 16:ph16040625. [PMID: 37111382 PMCID: PMC10142365 DOI: 10.3390/ph16040625] [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: 03/21/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The increasing use of immune checkpoint inhibitors (ICIs) in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in the incidence of cardiovascular (CV) immune-related adverse events (irAEs). The current follow-up guidelines are based on anecdotal evidence and expert opinions, due to a lack of solid data and prospective studies. As many questions remain unanswered, cardiac monitoring, in patients receiving ICIs, is not always implemented by oncologists. Hence, an urgent need to investigate the possible short- and long-term CV effects of ICIs, as ICI approval is continuing to expand to the (neo)adjuvant setting. METHODS We have initiated a prospective, multicenter study, i.e., the CAVACI trial, in which a minimum of 276 patients with a solid tumor, eligible for ICI treatment, will be enrolled. The study consists of routine investigations of blood parameters (troponin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, in particular) and a thorough CV follow-up (electrocardiograms, transthoracic echocardiograms, and coronary calcium scoring) at fixed time points for a total period of two years. The primary endpoint is the cumulative incidence of troponin elevation in the first three months of ICI treatment, compared to baseline levels. Furthermore, secondary endpoints include incidence above the upper limit of normal of both troponin and NT-proBNP levels, evolution in troponin and NT-proBNP levels, the incidence of CV abnormalities/major adverse cardiac events, evaluation of associations between patient characteristics/biochemical parameters and CV events, transthoracic echocardiography parameters, electrocardiography parameters, and progression of coronary atherosclerosis. Recruitment of patients started in January 2022. Enrolment is ongoing in AZ Maria Middelares, Antwerp University Hospital, AZ Sint-Vincentius Deinze, and AZ Sint-Elisabeth Zottegem. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05699915, registered 26 January 2023.
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Affiliation(s)
- Danielle Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | - Johan De Sutter
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | - Lieselot Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | | | | | - Nico Van de Veire
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Department of Cardiology, Free University Brussels, 1000 Brussels, Belgium
| | | | - 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
- 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
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Christof Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
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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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Wang D, Bauersachs J, Berliner D. Immune Checkpoint Inhibitor Associated Myocarditis and Cardiomyopathy: A Translational Review. BIOLOGY 2023; 12:biology12030472. [PMID: 36979163 PMCID: PMC10045178 DOI: 10.3390/biology12030472] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized oncology and transformed the treatment of various malignancies. By unleashing the natural immunological brake of the immune system, ICIs were initially considered an effective, gentle therapy with few side effects. However, accumulated clinical knowledge reveals that ICIs are associated with inflammation and tissue damage in multiple organs, leading to immune-related adverse effects (irAEs). Most irAEs involve the skin and gastrointestinal tract; however, cardiovascular involvement is associated with very high mortality rates, and its underlying pathomechanisms are poorly understood. Ranging from acute myocarditis to chronic cardiomyopathies, ICI-induced cardiotoxicity can present in various forms and entities. Revealing the inciting factors, understanding the pathogenesis, and identifying effective treatment strategies are needed to improve the care of tumor patients and our understanding of the immune and cardiovascular systems.
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Affiliation(s)
- Dong Wang
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
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Zirkenbach VA, Ignatz RM, Öttl R, Cehreli Z, Stroikova V, Kaya M, Lehmann LH, Preusch MR, Frey N, Kaya Z. Effect of SARS-CoV-2 mRNA-Vaccine on the Induction of Myocarditis in Different Murine Animal Models. Int J Mol Sci 2023; 24:ijms24055011. [PMID: 36902442 PMCID: PMC10002951 DOI: 10.3390/ijms24055011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 03/08/2023] Open
Abstract
In the course of the SARS-CoV-2 pandemic, vaccination safety and risk factors of SARS-CoV-2 mRNA-vaccines were under consideration after case reports of vaccine-related side effects, such as myocarditis, which were mostly described in young men. However, there is almost no data on the risk and safety of vaccination, especially in patients who are already diagnosed with acute/chronic (autoimmune) myocarditis from other causes, such as viral infections, or as a side effect of medication and treatment. Thus, the risk and safety of these vaccines, in combination with other therapies that could induce myocarditis (e.g., immune checkpoint inhibitor (ICI) therapy), are still poorly assessable. Therefore, vaccine safety, with respect to worsening myocardial inflammation and myocardial function, was studied in an animal model of experimentally induced autoimmune myocarditis. Furthermore, it is known that ICI treatment (e.g., antibodies (abs) against PD-1, PD-L1, and CTLA-4, or a combination of those) plays an important role in the treatment of oncological patients. However, it is also known that treatment with ICIs can induce severe, life-threatening myocarditis in some patients. Genetically different A/J (most susceptible strain) and C57BL/6 (resistant strain) mice, with diverse susceptibilities for induction of experimental autoimmune myocarditis (EAM) at various age and gender, were vaccinated twice with SARS-CoV-2 mRNA-vaccine. In an additional A/J group, an autoimmune myocarditis was induced. In regard to ICIs, we tested the safety of SARS-CoV-2 vaccination in PD-1-/- mice alone, and in combination with CTLA-4 abs. Our results showed no adverse effects related to inflammation and heart function after mRNA-vaccination, independent of age, gender, and in different mouse strains susceptible for induction of experimental myocarditis. Moreover, there was no worsening effect on inflammation and cardiac function when EAM in susceptible mice was induced. However, in the experiments with vaccination and ICI treatment, we observed, in some mice, low elevation of cardiac troponins in sera, and low scores of myocardial inflammation. In sum, mRNA-vaccines are safe in a model of experimentally induced autoimmune myocarditis, but patients undergoing ICI therapy should be closely monitored when vaccinated.
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Affiliation(s)
| | - Rebecca M. Ignatz
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Renate Öttl
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Zeynep Cehreli
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Vera Stroikova
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Mansur Kaya
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Lorenz H. Lehmann
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, 69120 Heidelberg, Germany
| | - Michael R. Preusch
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, 69120 Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, 69120 Heidelberg, Germany
| | - Ziya Kaya
- Department of Cardiology, University of Heidelberg, 69120 Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-5639617
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Kanbayashi Y, Shimizu T, Anzai M, Kawai R, Uchida M. Evaluation of Cardiac Adverse Events with Nivolumab Using a Japanese Real-World Database. Clin Drug Investig 2023; 43:177-184. [PMID: 36780109 DOI: 10.1007/s40261-023-01246-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Nivolumab has been used for the treatment of various types of cancers and has achieved improvements in overall survival. However, nivolumab can cause a variety of adverse events (AEs). Among these, cardiac-specific AEs have received little attention in clinical trials, despite their life-threatening potential. OBJECTIVE The present study aimed to determine the risk of nivolumab-induced cardiac AEs, time to onset, incidence rates, and post hoc outcomes using the Japanese Adverse Drug Event Report database. METHODS We analyzed data for the period between April 2004 and March 2021. Data on cardiac AEs were extracted and relative risk of AEs was estimated using the reporting odds ratio (ROR). RESULTS We analyzed 1,772,494 reports and identified 18,721 reports of AEs caused by nivolumab. Of these, 409 reports involved cardiac AEs. Signals were detected for four cardiac AEs: myocarditis; pericardial effusion; pericarditis; and immune-mediated myocarditis. Among these, myocarditis was the most frequently reported (35.0%) and included fatal cases. A histogram of times to onset showed nivolumab-associated AEs occurring 41-127 days after starting administration, with outlier cases of myocarditis or pericardial effusion occurring after more than one year, both with catastrophic consequences. CONCLUSION This study focused on cardiac AEs caused by nivolumab as post-marketing AEs. Myocarditis and pericardial effusion have been associated with some fatal cases after administration of nivolumab. Patients should be monitored for signs of onset for these AEs, not only at the start of administration, but also over an extended period after nivolumab administration.
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Affiliation(s)
- Yuko Kanbayashi
- Department of Education and Research Center for Clinical Pharmacy, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University, 4-20-1 Nasahara, Takatsuki, Osaka, 569-1094, Japan.
| | - Tadashi Shimizu
- School of Pharmacy, Hyogo Medical University, 1-3-6 Minatojima, Kobe, Hyogo, 650-8530, Japan
| | - Miku Anzai
- Department of Education and Research Center for Pharmacy Practice, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, 97-1 Kodominamihokotate, Kyotanabe, Kyoto, 610-0395, Japan
| | - Rika Kawai
- Department of Education and Research Center for Pharmacy Practice, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, 97-1 Kodominamihokotate, Kyotanabe, Kyoto, 610-0395, Japan
| | - Mayako Uchida
- Department of Education and Research Center for Pharmacy Practice, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, 97-1 Kodominamihokotate, Kyotanabe, Kyoto, 610-0395, Japan
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47
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Song W, Zheng Y, Dong M, Zhong L, Bazoukis G, Perone F, Li G, Ng CF, Baranchuk A, Tse G, Liu T. Electrocardiographic Features of Immune Checkpoint Inhibitor-Associated Myocarditis. Curr Probl Cardiol 2023; 48:101478. [PMID: 36336121 DOI: 10.1016/j.cpcardiol.2022.101478] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are associated with immune-related adverse events including myocarditis, whilst improving cancer-related outcomes. There is thus a clinical need to identify electrocardiographic manifestations of ICI-related myocarditis to guide clinical management. PubMed was searched for clinical studies and case reports describing electrocardiographic changes in patients with ICI-related myocarditis. A total of 6 clinical studies and 79 case reports were included. This revealed a range of presentations for patients on ICIs, including supraventricular arrhythmias, ventricular arrhythmias and heart block, and new changes of ST-T segment unrelated to coronary artery disease, ST-segment elevation or depression and T-wave abnormalities. Several patients showed low voltages in multiple leads and new onset Q-wave development. Patients with ICI-related myocarditis may develop new arrhythmia and ST-T changes, and infrequently low voltages in multiple leads.
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Affiliation(s)
- Wenhua Song
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yi Zheng
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Mei Dong
- Department of Cardiology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai Shandong, China
| | - Lin Zhong
- Department of Cardiology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai Shandong, China
| | - George Bazoukis
- Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus; Department of Basic and Clinical Sciences, University of Nicosia Medical School, 2414, Nicosia, Cyprus
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic "Villa delle Magnolie", Castel Morrone, Caserta, Italy
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Chi Fai Ng
- SH Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Science, Center, Queen's University, Kingston, Ontario, Canada
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China; Epidemiology Research Unit, Cardiovascular Analytics Group, Hong Kong, China; Kent and Medway Medical School, University of Kent and Canterbury Christ Church University, Canterbury, Kent, UK; School of Nursing and Health Studies, Hong Kong, Metropolitan University, Hong Kong, China.
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.
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Dora D, Bokhari SMZ, Aloss K, Takacs P, Desnoix JZ, Szklenárik G, Hurley PD, Lohinai Z. Implication of the Gut Microbiome and Microbial-Derived Metabolites in Immune-Related Adverse Events: Emergence of Novel Biomarkers for Cancer Immunotherapy. Int J Mol Sci 2023; 24:ijms24032769. [PMID: 36769093 PMCID: PMC9916922 DOI: 10.3390/ijms24032769] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 02/04/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have changed how we think about tumor management. Combinations of anti-programmed death ligand-1 (PD-L1) immunotherapy have become the standard of care in many advanced-stage cancers, including as a first-line therapy. Aside from improved anti-tumor immunity, the mechanism of action of immune checkpoint inhibitors (ICIs) exposes a new toxicity profile known as immune-related adverse effects (irAEs). This novel toxicity can damage any organ, but the skin, digestive and endocrine systems are the most frequently afflicted. Most ICI-attributed toxicity symptoms are mild, but some are severe and necessitate multidisciplinary side effect management. Obtaining knowledge on the various forms of immune-related toxicities and swiftly changing treatment techniques to lower the probability of experiencing severe irAEs has become a priority in oncological care. In recent years, there has been a growing understanding of an intriguing link between the gut microbiome and ICI outcomes. Multiple studies have demonstrated a connection between microbial metagenomic and metatranscriptomic patterns and ICI efficacy in malignant melanoma, lung and colorectal cancer. The immunomodulatory effect of the gut microbiome can have a real effect on the biological background of irAEs as well. Furthermore, specific microbial signatures and metabolites might be associated with the onset and severity of toxicity symptoms. By identifying these biological factors, novel biomarkers can be used in clinical practice to predict and manage potential irAEs. This comprehensive review aims to summarize the clinical aspects and biological background of ICI-related irAEs and their potential association with the gut microbiome and metabolome. We aim to explore the current state of knowledge on the most important and reliable irAE-related biomarkers of microbial origin and discuss the intriguing connection between ICI efficacy and toxicity.
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Affiliation(s)
- David Dora
- Department of Anatomy, Histology, and Embryology, Semmelweis University, Tuzolto St. 58, 1094 Budapest, Hungary
- Correspondence: (D.D.); (Z.L.)
| | | | - Kenan Aloss
- Translational Medicine Institute, Semmelweis University, 1094 Budapest, Hungary
| | - Peter Takacs
- Department of Anatomy, Histology, and Embryology, Semmelweis University, Tuzolto St. 58, 1094 Budapest, Hungary
| | - Juliane Zsuzsanna Desnoix
- Department of Anatomy, Histology, and Embryology, Semmelweis University, Tuzolto St. 58, 1094 Budapest, Hungary
| | - György Szklenárik
- Translational Medicine Institute, Semmelweis University, 1094 Budapest, Hungary
| | | | - Zoltan Lohinai
- Translational Medicine Institute, Semmelweis University, 1094 Budapest, Hungary
- National Korányi Institute of Pulmonology, Pihenő út 1-3, 1121 Budapest, Hungary
- Correspondence: (D.D.); (Z.L.)
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49
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Madanat L, Gupta R, Weber P, Kumar N, Chandra R, Ahaneku H, Bansal Y, Anderson J, Bilolikar A, Jaiyesimi I. Cardiotoxicity of Biological Therapies in Cancer Patients: An In-depth Review. Curr Cardiol Rev 2023; 19:e310522205428. [PMID: 35642110 PMCID: PMC10280990 DOI: 10.2174/1573403x18666220531094800] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 11/22/2022] Open
Abstract
Cardiotoxicity from chemotherapy regimens has been long reported. However, the understanding of cardiac side effects of biological therapies is rapidly evolving. With cancer patients achieving higher life expectancy due to the use of personalized medicine and novel targeted anticancer agents, the occurrence of cardiotoxicity is becoming more significant. Novel biological therapies include anti-HER2 antibodies, tyrosine kinase inhibitors, bruton kinase inhibitors, antivascular endothelial growth factors, proteasome inhibitors, immunomodulator drugs, and immune checkpoint inhibitors. Potential cardiovascular toxicities linked to these anticancer agents include hypertension, arrhythmias, QT prolongation, myocardial ischemia and infarction, left ventricular dysfunction, congestive heart failure, and thromboembolism. Cardiac biomarkers, electrocardiography, echocardiography and magnetic resonance imaging are common diagnostic modalities used for early detection of these complications and timely intervention. This review discusses the various types of cardiotoxicities caused by novel anticancer biologic agents, their molecular and pathophysiological mechanisms, risk factors, and diagnostic and management strategies that can be used to prevent, minimize, and treat them.
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Affiliation(s)
- Luai Madanat
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Ruby Gupta
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Paul Weber
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
| | - Navneet Kumar
- Department of Cardiovascular Disease, St. Joseph Mercy Oakland Hospital, Pontiac, Michigan
| | - Rohit Chandra
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Hycienth Ahaneku
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Yatharth Bansal
- Department of Internal Medicine, University of Detroit Mercy, Detroit, Michigan
| | - Joseph Anderson
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Abhay Bilolikar
- Department of Cardiovascular Disease, William Beaumont Hospital, Royal Oak, Michigan
| | - Ishmael Jaiyesimi
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan
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50
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Grigorescu A, Teodorescu M. Toxicitatea cardiacă a inhibitorilor punctelor de control (IPC) utilizaţi în imunoterapia cancerului. ONCOLOG-HEMATOLOG.RO 2023. [DOI: 10.26416/onhe.62.1.2023.7746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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