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Kopp LM, Womer RB, Schwartz CL, Ebb DH, Franco VI, Hall D, Barkauskas DA, Krailo MD, Grier HE, Meyers PA, Wexler LH, Marina NM, Janeway KA, Gorlick R, Bernstein ML, Lipshultz SE. Effects of dexrazoxane on doxorubicin-related cardiotoxicity and second malignant neoplasms in children with osteosarcoma: a report from the Children's Oncology Group. Cardiooncology 2019; 5:15. [PMID: 32154021 PMCID: PMC7048050 DOI: 10.1186/s40959-019-0050-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/10/2019] [Indexed: 11/12/2022]
Abstract
Background Dexrazoxane protects from lower-cumulative-dose doxorubicin cardiotoxicity, but the effect of dexrazoxane in children with sarcoma treated with higher-cumulative-dose doxorubicin is unknown. Methods We evaluated children with osteosarcoma (OS) on two Children's Oncology Group trials with higher dose doxorubicin (375-600 mg/m2) preceded by dexrazoxane (10:1 dexrazoxane:doxorubicin dosing). They were evaluated after the minimum expected treatment time (METT), defined as 28 weeks. Cardiotoxicity was identified by echocardiography and serum N-terminal pro-brain natriuretic peptide (NT-proBNP). Second malignant neoplasm (SMN) data was collected. Results All children had normal left ventricular (LV) systolic function as measured by LV fractional shortening and no heart failure. The end-diastolic septal thickness Z-scores (P < 0.01) and LV mass Z-scores (P < 0.01) were significantly smaller than normal for body-surface area in both sexes. The average LV mass Z-scores were significantly smaller for girls (P < 0.01) and marginally smaller for boys (P = 0.06). Girls had significantly smaller LV end-diastolic dimension Z-scores normalized to BSA (P < 0.01) compared to healthy controls and had significant increases in NT-proBNP. Four children developed SMNs as first events, a rate similar to historical controls. Conclusions Dexrazoxane prevented LV dysfunction and heart failure in children with OS receiving higher dose doxorubicin. However, LV structural changes were not fully prevented, especially in girls. As a result, hearts become abnormally small for body size, resulting in higher LV stress. Dexrazoxane did not increase the risk of SMN. Dexrazoxane should be used in this population, particularly for girls, to mitigate anthracycline-induced cardiotoxicity. Trial registrations ClinicalTrials.gov: NCT00003937 (P9754) registered 1 Nov 1999, and NCT00023998 (AOST0121) registered 13 Sept 2001.
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Affiliation(s)
- Lisa M Kopp
- 1Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, 1295 N Martin Ave. PO Box 245210, Tucson, AZ 85724 USA.,2University of Arizona Cancer Center, University of Arizona, Tucson, AZ USA
| | | | - Cindy L Schwartz
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI USA
| | - David H Ebb
- 5Department of Pediatric Hematology-Oncology, Massachusetts General Hospital, Boston, MA USA
| | - Vivian I Franco
- 6Department of Pediatrics, University at Buffalo, Oishei Children's Hospital, Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
| | - David Hall
- 7Children's Oncology Group, Monrovia, CA USA
| | - Donald A Barkauskas
- 7Children's Oncology Group, Monrovia, CA USA.,8Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | - Mark D Krailo
- 7Children's Oncology Group, Monrovia, CA USA.,8Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | | | - Paul A Meyers
- 10Memorial Sloan Kettering Cancer Center, New York, NY USA
| | | | - Neyssa M Marina
- 11Five Prime Therapeutics, Inc., South San Francisco, CA USA
| | | | | | | | - Steven E Lipshultz
- 6Department of Pediatrics, University at Buffalo, Oishei Children's Hospital, Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
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Lipshultz S, Blonquist TM, Miller TL, Neuberg DS, Smith HM, Anderson B, Franco VI, Bansal N, Lipshultz ER, Scully RE, Silverman LB, Colan SD, Asselin BL, Athale U, Clavell LA, Laverdiere C, Michon B, Schorin MA, Sallan SE, Sawyer D. CARDIOVASCULAR SIGNALING PROTEINS AS PREDICTORS OF DOXORUBICIN-RELATED CARDIAC EFFECTS IN CHILDREN WITH ACUTE LYMPHOBLASTIC LEUKEMIA. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31468-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hutchins KK, Siddeek H, Franco VI, Lipshultz SE. Prevention of cardiotoxicity among survivors of childhood cancer. Br J Clin Pharmacol 2016; 83:455-465. [PMID: 27591829 DOI: 10.1111/bcp.13120] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 12/22/2022] Open
Abstract
LINKED ARTICLES This article is part of a joint Themed section with the British Journal of Pharmacology on Cardiotoxicity. The rest of the Themed section will appear in a future issue of BJP and will be available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1476-5381 The number of survivors of childhood cancers has increased exponentially over the past few decades. However, these survivors are also at substantially increased long-term risk of morbidity and mortality, especially from treatment-related cardiotoxicity. Preventing these risks is now a priority when treating children and adolescents with cancer. Dexrazoxane reduces the risk of anthracycline-induced cardiotoxicity among adults and children with cancer without reducing its antineoplastic effects or event-free survival. Thus, it should be strongly considered as a part of therapy for children and adolescents treated with anthracyclines.
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Affiliation(s)
- Kelley K Hutchins
- Department of Pediatric Hematology/Oncology, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, Michigan, 48201, USA
| | - Hani Siddeek
- Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, Michigan, 48201, USA
| | - Vivian I Franco
- Department of Pediatrics, Wayne State University School of Medicine, 3901 Beaubien Boulevard, Suite 1K40, Detroit, Michigan, 48201, USA
| | - Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine, 3901 Beaubien Boulevard, Suite 1K40, Detroit, Michigan, 48201, USA.,Karmanos Cancer Institute, Children's Hospital of Michigan
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Abstract
OPINION STATEMENT Cardiovascular-related morbidity is a substantial health burden in survivors of childhood cancers. This burden is gaining importance as this population increases through advancements in therapy. Anthracyclines are commonly used agents that are known to cause late cardiotoxicity. Cardiotoxicity is also increased by other risk factors, such as concurrent radio- or chemotherapy, younger age at diagnosis, female sex, comorbidities, lifestyle factors, and genetic factors, such as hemochromatosis gene mutations. Treatment of late cardiotoxicity depends on the type of cardiac abnormalities and consists of pharmacotherapy, mechanical support, or heart transplantation. Because cardiotoxicity is progressive and often irreversible, prevention, risk reduction, and early detection are of utmost importance. The cardioprotectant dexrazoxane decreases anthracycline cardiotoxicity. Screening for other risk factors at the time of diagnosis may identify risk that when present, if used to tailor therapy, may reduce the severity of cardiac damage. The effects of exercise and other lifestyle changes in reducing the cardiovascular diseases in cancer survivors are unclear. However, it may be beneficial to encourage survivors to engage in physical activity tailored to survivor medical status, but with close monitoring.
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Affiliation(s)
- Jyothsna Akam-Venkata
- Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Suite 1K40, Detroit, MI, 48201, USA
| | - Vivian I Franco
- Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Suite 1K40, Detroit, MI, 48201, USA
| | - Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Suite 1K40, Detroit, MI, 48201, USA.
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Lipshultz SE, Anderson LM, Miller TL, Gerschenson M, Stevenson KE, Neuberg DS, Franco VI, LiButti DE, Silverman LB, Vrooman LM, Sallan SE. Impaired mitochondrial function is abrogated by dexrazoxane in doxorubicin-treated childhood acute lymphoblastic leukemia survivors. Cancer 2016; 122:946-53. [PMID: 26762648 PMCID: PMC4777628 DOI: 10.1002/cncr.29872] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 11/29/2015] [Accepted: 12/04/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Impaired cardiac function in doxorubicin-treated childhood cancer survivors is partly mediated by the disruption of mitochondrial energy production. Doxorubicin intercalates into mitochondrial DNA (mtDNA) and disrupts genes encoding for polypeptides that make adenosine triphosphate. METHODS This cross-sectional study examined mtDNA copy numbers per cell and oxidative phosphorylation (OXPHOS) in peripheral blood mononuclear cells (PBMCs) in 64 childhood survivors of high-risk acute lymphoblastic leukemia (ALL) who had been treated on Dana-Farber Cancer Institute childhood ALL protocols and had received doxorubicin alone (42%) or doxorubicin with the cardioprotectant dexrazoxane (58%). The number of mtDNA copies per cell and the OXPHOS enzyme activity of nicotinamide adenine dinucleotide dehydrogenase (complex I [CI]) and cytochrome c oxidase (complex IV [CIV]) were measured with quantitative real-time polymerase chain reaction immunoassays and thin-layer chromatography, respectively. RESULTS At a median follow-up of 7.8 years after treatment, the median number of mtDNA copies per cell for patients treated with doxorubicin alone (1106.3) was significantly higher than the median number for those who had also received dexrazoxane (310.5; P = .001). No significant differences were detected between the groups for CI or CIV activity. CONCLUSIONS Doxorubicin-treated survivors had an increased number of PBMC mtDNA copies per cell, and concomitant use of dexrazoxane was associated with a lower number of mtDNA copies per cell. Because of a possible compensatory increase in mtDNA copies per cell to maintain mitochondrial function in the setting of mitochondrial dysfunction, overall OXPHOS activity was not different between the groups. The long-term sustainability of this compensatory response in these survivors at risk for cardiac dysfunction over their lifespan is concerning.
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MESH Headings
- Adolescent
- Antibiotics, Antineoplastic/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cardiotonic Agents/therapeutic use
- Child
- Child, Preschool
- Chromatography, Thin Layer
- Cross-Sectional Studies
- DNA Copy Number Variations/drug effects
- DNA, Mitochondrial/drug effects
- Dexrazoxane/therapeutic use
- Doxorubicin/administration & dosage
- Doxorubicin/adverse effects
- Electron Transport Complex I/drug effects
- Electron Transport Complex I/metabolism
- Electron Transport Complex IV/drug effects
- Electron Transport Complex IV/metabolism
- Female
- Follow-Up Studies
- Humans
- Infant
- Leukocytes, Mononuclear/drug effects
- Leukocytes, Mononuclear/enzymology
- Leukocytes, Mononuclear/metabolism
- Male
- Mitochondria, Heart/drug effects
- Mitochondria, Heart/genetics
- Mitochondria, Heart/metabolism
- Oxidation-Reduction
- Phosphorylation
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/metabolism
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/pathology
- Real-Time Polymerase Chain Reaction
- Sex Factors
- Survivors
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Affiliation(s)
- Steven E. Lipshultz
- Wayne State University School of Medicine and Children’s Hospital of Michigan, Detroit, MI
| | - Lynn M. Anderson
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI
| | | | - Mariana Gerschenson
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI
| | | | | | - Vivian I. Franco
- Wayne State University School of Medicine and Children’s Hospital of Michigan, Detroit, MI
| | - Daniel E. LiButti
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI
| | - Lewis B. Silverman
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Lynda M. Vrooman
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Stephen E. Sallan
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
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Asselin BL, Devidas M, Chen L, Franco VI, Pullen J, Borowitz MJ, Hutchison RE, Ravindranath Y, Armenian SH, Camitta BM, Lipshultz SE. Cardioprotection and Safety of Dexrazoxane in Patients Treated for Newly Diagnosed T-Cell Acute Lymphoblastic Leukemia or Advanced-Stage Lymphoblastic Non-Hodgkin Lymphoma: A Report of the Children's Oncology Group Randomized Trial Pediatric Oncology Group 9404. J Clin Oncol 2015; 34:854-62. [PMID: 26700126 DOI: 10.1200/jco.2015.60.8851] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To determine the oncologic efficacy, cardioprotective effectiveness, and safety of dexrazoxane added to chemotherapy that included a cumulative doxorubicin dose of 360 mg/m(2) to treat children and adolescents with newly diagnosed T-cell acute lymphoblastic leukemia (T-ALL) or lymphoblastic non-Hodgkin lymphoma (L-NHL). PATIENTS AND METHODS Patients were treated on Pediatric Oncology Group Protocol POG 9404, which included random assignment to treatment with or without dexrazoxane given as a bolus infusion immediately before every dose of doxorubicin. Cardiac effects were assessed by echocardiographic measurements of left ventricular function and structure. RESULTS Of 573 enrolled patients, 537 were eligible, evaluable, and randomly assigned to an arm with or without dexrazoxane. The 5-year event-free survival (with standard error) did not differ between groups: 77.2% (2.7%) for the dexrazoxane group versus 76.0% (2.7%) for the doxorubicin-only group (P = .9). The frequencies of severe grade 3 or 4 hematologic toxicity, infection, CNS events, and toxic deaths were similar in both groups (P ranged from .26 to .64). Of 11 second malignancies, eight occurred in patients who received dexrazoxane (P = .17). The mean left ventricular fractional shortening, wall thickness, and thickness-to-dimension ratio z scores measured 3 years after diagnosis were worse in the doxorubicin-alone group (n = 55 per group; P ≤ .01 for all comparisons). Mean fractional shortening z scores measured 3.5 to 6.4 years after diagnosis remained diminished and were lower in the 21 patients who received doxorubicin alone than in the 31 patients who received dexrazoxane (-2.03 v -0.24; P ≤ .001). CONCLUSION Dexrazoxane was cardioprotective and did not compromise antitumor efficacy, did not increase the frequencies of toxicities, and was not associated with a significant increase in second malignancies with this doxorubicin-containing chemotherapy regimen. We recommend dexrazoxane as a cardioprotectant for children and adolescents who have malignancies treated with anthracyclines.
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Affiliation(s)
- Barbara L Asselin
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI.
| | - Meenakshi Devidas
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Lu Chen
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Vivian I Franco
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Jeanette Pullen
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Michael J Borowitz
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Robert E Hutchison
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Yaddanapudi Ravindranath
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Saro H Armenian
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Bruce M Camitta
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
| | - Steven E Lipshultz
- Barbara L. Asselin, University of Rochester School of Medicine and Wilmot Cancer Institute, Rochester; Robert E. Hutchison, State University of New York Upstate Medical Center, Syracuse, NY; Meenakshi Devidas, Children's Oncology Group and University of Florida, Gainesville, FL; Lu Chen, Children's Oncology Group, Monrovia; Saro H. Armenian, City of Hope National Medical Center, Duarte, CA; Vivian I. Franco, Yaddanapudi Ravindranath, and Steven E. Lipshultz, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI; Jeanette Pullen, University of Mississippi Medical Center and Children's Hospital, Jackson, MS; Michael J. Borowitz, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD; and Bruce M. Camitta, Medical College of Wisconsin, Midwest Center for Cancer and Blood Disorders, Milwaukee, WI
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Lipshultz SE, Minotti G, Carver J, Franco VI. An Invitation from the Editors of Cardio-Oncology. Cardiooncology 2015; 1:2. [PMID: 33530142 PMCID: PMC7837149 DOI: 10.1186/s40959-015-0004-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 10/29/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine, the Children's Research Center of Michigan, and the Children's Hospital of Michigan, Detroit, MI, USA.
| | - Giorgio Minotti
- Drug Sciences and Clinical Pharmacology, University Campus Bio-Medico, Rome, Italy
| | - Joseph Carver
- Abramson Cancer Center of University of Pennsylvania Philadelphia, Philadelphia, PA, USA
| | - Vivian I Franco
- Department of Pediatrics, Wayne State University School of Medicine, the Children's Research Center of Michigan, and the Children's Hospital of Michigan, Detroit, MI, USA
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Petricoin EF, Ross MM, Zhou W, Tamburro D, Luchini A, Liotta LA, Herman EH, Scully RE, Miller TL, Franco VI, Sallan SE, Lipshultz SE. Development and pilot evaluation of a new nanoparticle-capture workflow for doxorubicin-induced toxicity biomarker identification. Progress in Pediatric Cardiology 2015. [DOI: 10.1016/j.ppedcard.2015.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Treatment advances have increased survival in children with cancer, but subclinical, progressive, irreversible, and sometimes fatal treatment-related cardiovascular effects may appear years later. Cardio-oncologists have identified promising preventive and treatment strategies. Dexrazoxane provides long-term cardioprotection from doxorubicin-associated cardiotoxicity without compromising the efficacy of anticancer treatment. Continuous infusion of doxorubicin is as effective as bolus administration in leukemia treatment, but no evidence has indicated that it provides long-term cardioprotection; continuous infusions should be eliminated from pediatric cancer treatment. Angiotensin-converting enzyme inhibitors can delay the progression of subclinical and clinical cardiotoxicity. All survivors, regardless of whether they were treated with anthracyclines or radiation, should be monitored for systemic inflammation and the risk of premature cardiovascular disease. Echocardiographic screening must be supplemented with screening for biomarkers of cardiotoxicity and perhaps by identification of genetic susceptibilities to cardiovascular diseases; optimal strategies need to be identified. The health burden related to cancer treatment will increase as this population expands and ages.
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Affiliation(s)
- Steven E. Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan 48201
- Children’s Hospital of Michigan, Detroit, Michigan 48201
| | - Vivian I. Franco
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan 48201
| | - Tracie L. Miller
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida 33101
| | - Steven D. Colan
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts 02115
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115
| | - Stephen E. Sallan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115
- Division of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts 02215
- Boston Children’s Hospital, Boston, Massachusetts 02115
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Lipshultz SE, Diamond MB, Franco VI, Aggarwal S, Leger K, Santos MV, Sallan SE, Chow EJ. Managing chemotherapy-related cardiotoxicity in survivors of childhood cancers. Paediatr Drugs 2014; 16:373-89. [PMID: 25134924 PMCID: PMC4417358 DOI: 10.1007/s40272-014-0085-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the US, children diagnosed with cancer are living longer, but not without consequences from the same drugs that cured their cancer. In these patients, cardiovascular disease is the leading cause of non-cancer-related morbidity and mortality. Although this review focuses on anthracycline-related cardiomyopathy in childhood cancer survivors, the global lifetime risk of other cardiovascular diseases such as atherosclerosis, arrhythmias and intracardiac conduction abnormalities, hypertension, and stroke also are increased. Besides anthracyclines, newer molecularly targeted agents, such as vascular endothelial growth factor receptor and tyrosine kinase inhibitors, also have been associated with acute hypertension, cardiomyopathy, and increased risk of ischemic cardiac events and arrhythmias, and are summarized here. This review also covers other risk factors for chemotherapy-related cardiotoxicity (including both modifiable and non-modifiable factors), monitoring strategies (including both blood and imaging-based biomarkers) during and following cancer treatment, and discusses the management of cardiotoxicity (including prevention strategies such as cardioprotection by use of dexrazoxane).
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Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine and the Children's Research Center of Michigan at the Children's Hospital of Michigan, 3901 Beaubien Boulevard, Suite 1K40, Detroit, MI, 48201, USA,
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11
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Abstract
Children diagnosed with cancer are now living longer as a result of advances in treatment. However, some commonly used anticancer drugs, although effective in curing cancer, can also cause adverse late effects. The cardiotoxic effects of anthracycline chemotherapy, such as doxorubicin, and radiation can cause persistent and progressive cardiovascular damage, emphasizing a need for effective prevention and treatment to reduce or avoid cardiotoxicity. Examples of risk factors for cardiotoxicity in children include higher anthracycline cumulative dose, higher dose of radiation, younger age at diagnosis, female sex, trisomy 21 and black race. However, not all who are exposed to toxic treatments experience cardiotoxicity, suggesting the possibility of a genetic predisposition. Cardioprotective strategies under investigation include the use of dexrazoxane, which provides short- and long-term cardioprotection in children treated with doxorubicin without interfering with oncological efficacy, the use of less toxic anthracycline derivatives and nutritional supplements. Evidence-based monitoring and screening are needed to identify early signs of cardiotoxicity that have been validated as surrogates of subsequent clinically significant cardiovascular disease before the occurrence of cardiac damage, in patients who may be at higher risk.
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Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Fla., USA
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Lipshultz SE, Franco VI, Sallan SE, Adamson PC, K. Steiner R, Swain SM, Gligorov J, Minotti G. Dexrazoxane for reducing anthracycline-related cardiotoxicity in children with cancer: An update of the evidence. Progress in Pediatric Cardiology 2014. [DOI: 10.1016/j.ppedcard.2014.09.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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13
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Steiner RK, Franco VI, Lipshultz SE. How do we improve the long-term consequences of cardiotoxicity in survivors of childhood cancer? Progress in Pediatric Cardiology 2014. [DOI: 10.1016/j.ppedcard.2014.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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14
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Bansal N, Franco VI, Lipshultz SE. Anthracycline cardiotoxicity in survivors of childhood cancer: Clinical course, protection, and treatment. Progress in Pediatric Cardiology 2014. [DOI: 10.1016/j.ppedcard.2014.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Triple negative breast cancer (TNBC) presents clinical challenges due to unknown etiology, lack of treatment targets, and poor prognosis. We examined combined genetic and nutritional risk models of TNBC in 354 breast cancer cases. We evaluated 18 DNA-repair nonsynonymous single nucleotide polymorphisms (nsSNPs) and dietary/nutritional intakes. Multivariate Adaptive Regression Splines models were used to select nutrients of interest and define cut-off values for logistic regression models. Our results suggest that TNBC was associated with 6 DNA-repair nsSNPs, ERCC4 R415Q (rs1800067), MSH3 R940Q (rs184967), MSH6 G39E (rs1042821), POLD1 R119H (rs1726801), XRCC1 R194W (rs1799782), and XPC A499V (rs2228000) and/or deficiencies in 3 micronutrients (zinc, folate, and β-carotene). Combined analyses of these 6 nsSNPs and 3 micronutrients showed significant association with TNBC: odds ratios = 2.77 (95% confidence interval = 1.01-7.64) and 10.89 (95% confidence interval = 3.50-33.89) for 2 and at least 3 risk factors, respectively. To the best of our knowledge, this is the first study to suggest that multiple genetic and nutritional factors are associated with TNBC, particularly in combination. Our findings, if validated in larger studies, will have important clinical implication that dietary modulations and/or micronutrient supplementations may prevent or reverse TNBC phenotype, so tumors can be treated with less toxic therapeutic strategies, particularly in genetically susceptible women.
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Affiliation(s)
- Eunkyung Lee
- a Department of Public Health Sciences and Sylvester Comprehensive Cancer Center , University of Miami Miller School of Medicine , Miami , Florida , USA
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Lipshultz SE, Scully RE, Stevenson KE, Franco VI, Neuberg DS, Colan SD, Silverman LB, Moslehi JJ, Cheng S, Sallan SE. Hearts too small for body size after doxorubicin for childhood ALL: Grinch syndrome. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.10021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Steven D Colan
- Department of Cardiology, Children's Hospital, Boston, MA
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17
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Abstract
OPINION STATEMENT Anthracyclines have been widely used in children and adults to treat hematologic malignancies, soft-tissue sarcomas, and solid tumors. However, anthracyclines come with both short- and long-term cardiotoxic effects, ranging from occult changes in myocardial structure and function to severe cardiomyopathy and heart failure that may result in cardiac transplantation or death. Here, we review the progress made over the past two decades in understanding the molecular and genetic basis of anthracycline-induced cardiotoxicity; detecting and monitoring myocardial dysfunction; using adjunct cardioprotectant therapies, such as dexrazoxane; and improving cardioprotection with agents such as liposomal and pegylated doxorubicin. Despite this increased understanding, preventing drug-induced cardiotoxicity while maintaining oncologic efficacy to achieve the highest quality of life over a lifespan remain cornerstones of successful anthracycline chemotherapy during childhood.
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Affiliation(s)
- Shashi Raj
- Department of Pediatrics, Division of Pediatric Cardiology, University of Miami Miller School of Medicine, Miami, FL, USA
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Seifert SM, Seifert SA, Schaechter JL, Hershorin ER, Arheart KL, Franco VI, Bronstein AC, Benson BE, Lipshultz SE. In reply to “Interpretation of ‘An analysis of energy-drink toxicity in the National Poison Data System’”. Clin Toxicol (Phila) 2014; 52:234-5. [DOI: 10.3109/15563650.2014.888446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lipshultz SE, Lipsitz SR, Kutok JL, Miller TL, Colan SD, Neuberg DS, Stevenson KE, Fleming MD, Sallan SE, Franco VI, Henkel JM, Asselin BL, Athale UH, Clavell LA, Michon B, Laverdiere C, Larsen E, Kelly KM, Silverman LB. Impact of hemochromatosis gene mutations on cardiac status in doxorubicin-treated survivors of childhood high-risk leukemia. Cancer 2013; 119:3555-62. [PMID: 23861158 PMCID: PMC3788065 DOI: 10.1002/cncr.28256] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/06/2013] [Accepted: 06/12/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Doxorubicin is associated with progressive cardiac dysfunction, possibly through the formation of doxorubicin-iron complexes leading to free-radical injury. The authors determined the frequency of hemochromatosis (HFE) gene mutations associated with hereditary hemochromatosis and their relationship with doxorubicin-associated cardiotoxicity in survivors of childhood high-risk acute lymphoblastic leukemia. METHODS Peripheral blood was tested for 2 common HFE allelic variants: C282Y and H63D. Serum cardiac troponin-T (cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP), which are biomarkers of cardiac injury and cardiomyopathy, respectively, were assayed during therapy. Left ventricular (LV) structure and function were assessed with echocardiography. RESULTS A total of 184 patients had DNA results for at least 1 variant, and 167 had DNA results for both: 24% carried H63D and 10% carried C282Y. Heterozygous C282Y genotype was associated with multiple elevations in cTnT concentrations (P = .039), but not NT-proBNP. At a median of 2.2 years (range, 1.0 years-3.6 years) after diagnosis, the mean Z-scores for LV fractional shortening (-0.71 [standard error (SE), 0.25]; P = .008), mass (-0.84 [SE, 0.17]; P < .001), and end-systolic (-4.36 [SE, 0.26], P < .001) and end-diastolic (-0.68 [SE, 0.25]; P = .01) posterior wall thickness were found to be abnormal in children with either allele (n = 32). Noncarriers (n = 63) also were found to have below-normal LV mass (-0.45 [SE, 0.15]; P = .006) and end-systolic posterior wall thickness (-4.06 [SE, 0.17]; P < .001). Later follow-up demonstrated similar results. CONCLUSIONS Doxorubicin-associated myocardial injury was associated with C282Y HFE carriers. Although LV mass and wall thickness were found to be abnormally low overall, they were even lower in HFE carriers, who also had reduced LV function. Screening newly diagnosed cancer patients for HFE mutations may identify those at risk for doxorubicin-induced cardiotoxicity.
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Affiliation(s)
- Steven E. Lipshultz
- University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | | | | | - Tracie L. Miller
- University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Steven D. Colan
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | | | - Mark D. Fleming
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Stephen E. Sallan
- Boston Children's Hospital, Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | - Vivian I. Franco
- University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Jacqueline M. Henkel
- University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | | | | | | | - Bruno Michon
- Centre Hospitalier Universitaire de Quebec Quebec City, QC, Canada
| | | | - Eric Larsen
- Maine Children's Cancer Program Portland, ME
| | | | - Lewis B. Silverman
- Boston Children's Hospital, Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
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Lipshultz SE, Franco VI, Cochran TR. Cardiotoxicity in childhood cancer survivors: a problem with long-term consequences in need of early detection and prevention. Pediatr Blood Cancer 2013; 60:1395-6. [PMID: 23712966 DOI: 10.1002/pbc.24597] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 04/22/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida 33101, USA.
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21
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Seifert SM, Seifert SA, Schaechter JL, Bronstein AC, Benson BE, Hershorin ER, Arheart KL, Franco VI, Lipshultz SE. An analysis of energy-drink toxicity in the National Poison Data System. Clin Toxicol (Phila) 2013; 51:566-74. [DOI: 10.3109/15563650.2013.820310] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Sara M. Seifert
- Department of Pediatrics, University of Miami Miller School of Medicine,
Miami, FL, USA
| | - Steven A. Seifert
- Department of Emergency Medicine, University of New Mexico School of Medicine,
Albuquerque, NM, USA
- New Mexico Poison and Drug Information Center,
Albuquerque, NM, USA
| | - Judy L. Schaechter
- Department of Pediatrics, University of Miami Miller School of Medicine,
Miami, FL, USA
- Division of Adolescent Medicine, University of Miami Miller School of Medicine,
Miami, FL, USA
- Holtz Children's Hospital of the Jackson Health System,
Miami, FL, USA
| | - Alvin C. Bronstein
- Rocky Mountain Poison Center, University of Colorado School of Medicine, Denver Health,
Denver, CO, USA
| | - Blaine E. Benson
- New Mexico Poison and Drug Information Center,
Albuquerque, NM, USA
| | - Eugene R. Hershorin
- Department of Pediatrics, University of Miami Miller School of Medicine,
Miami, FL, USA
- Holtz Children's Hospital of the Jackson Health System,
Miami, FL, USA
| | - Kristopher L. Arheart
- Department of Pediatrics, University of Miami Miller School of Medicine,
Miami, FL, USA
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine,
Miami, FL, USA
- Division of Pediatric Clinical Research, Batchelor Children's Research Institute, University of Miami Miller School of Medicine,
Miami, FL, USA
| | - Vivian I. Franco
- Department of Pediatrics, University of Miami Miller School of Medicine,
Miami, FL, USA
- Division of Pediatric Clinical Research, Batchelor Children's Research Institute, University of Miami Miller School of Medicine,
Miami, FL, USA
- Program for Pediatric Integrative Medicine, University of Miami Miller School of Medicine,
Miami, FL, USA
| | - Steven E. Lipshultz
- Department of Pediatrics, University of Miami Miller School of Medicine,
Miami, FL, USA
- Division of Pediatric Clinical Research, Batchelor Children's Research Institute, University of Miami Miller School of Medicine,
Miami, FL, USA
- Program for Pediatric Integrative Medicine, University of Miami Miller School of Medicine,
Miami, FL, USA
- Holtz Children's Hospital of the Jackson Health System,
Miami, FL, USA
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Zerra P, Cochran TR, Franco VI, Lipshultz SE. An expert opinion on pharmacologic approaches to reducing the cardiotoxicity of childhood acute lymphoblastic leukemia therapies. Expert Opin Pharmacother 2013; 14:1497-513. [PMID: 23705955 DOI: 10.1517/14656566.2013.804911] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Acute lymphoblastic leukemia (ALL) is the most common hematologic malignancy in children. Treatment-related cardiac damage is progressive and often difficult to reverse. Strategies to minimize cardiotoxicity during treatment are crucial to prevent severe lasting effects on health and quality of life. AREAS COVERED This comprehensive review covers the pathophysiology and various presentations, both clinical and subclinical, of treatment-induced cardiotoxicity and characteristics associated with increased risk of cardiac dysfunction in childhood ALL survivors. Additionally, contemporary prevention strategies such as limiting cumulative anthracycline dose, altering drug administration schedule, the use of anthracycline structural analogs, liposomal encapsulated anthracyclines, cardioprotective agents and nutritional supplements are critically analyzed. Finally, this review covers the management options of chemotherapy-induced damage and other treatment-related cardiotoxicity. EXPERT OPINION Higher lifetime cumulative doses of anthracyclines, younger age at diagnosis, longer follow-up, female sex, higher dose rates and cranial irradiation are associated with more severe cardiotoxic effects. Long-term adverse effects of both anthracycline and non-anthracycline chemotherapeutic agents are becoming an increasing focus during treatment of childhood malignancies. There must be a careful balance between achieving remission of childhood ALL while avoiding the development of another often-fatal illness, heart failure.
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Affiliation(s)
- Patricia Zerra
- University of Miami Miller School of Medicine, Department of Pediatrics (D820), P.O. Box 016820, Miami, FL 33101, USA
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23
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Lipshultz SE, Miller TL, Lipsitz SR, Neuberg DS, Dahlberg SE, Colan SD, Silverman LB, Henkel JM, Franco VI, Cushman LL, Asselin BL, Clavell LA, Athale U, Michon B, Laverdière C, Schorin MA, Larsen E, Usmani N, Sallan SE. Continuous Versus Bolus Infusion of Doxorubicin in Children With ALL: Long-term Cardiac Outcomes. Pediatrics 2012; 130:1003-11. [PMID: 23166343 PMCID: PMC3507254 DOI: 10.1542/peds.2012-0727] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Doxorubicin, effective against many malignancies, is limited by cardiotoxicity. Continuous-infusion doxorubicin, compared with bolus-infusion, reduces early cardiotoxicity in adults. Its effectiveness in reducing late cardiotoxicity in children remains uncertain. We determined continuous-infusion doxorubicin cardioprotective efficacy in long-term survivors of childhood acute lymphoblastic leukemia (ALL). METHODS The Dana-Farber Cancer Institute ALL Consortium Protocol 91-01 enrolled pediatric patients between 1991 and 1995. Newly diagnosed high-risk patients were randomly assigned to receive a total of 360 mg/m(2) of doxorubicin in 30 mg/m(2) doses every 3 weeks, by either continuous (over 48 hours) or bolus-infusion (within 15 minutes). Echocardiograms at baseline, during, and after doxorubicin therapy were blindly remeasured centrally. Primary outcomes were late left ventricular (LV) structure and function. RESULTS A total of 102 children were randomized to each treatment group. We analyzed 484 serial echocardiograms from 92 patients (n = 49 continuous; n = 43 bolus) with ≥1 echocardiogram ≥3 years after assignment. Both groups had similar demographics and normal baseline LV characteristics. Cardiac follow-up after randomization (median, 8 years) showed changes from baseline within the randomized groups (depressed systolic function, systolic dilation, reduced wall thickness, and reduced mass) at 3, 6, and 8 years; there were no statistically significant differences between randomized groups. Ten-year ALL event-free survival rates did not differ between the 2 groups (continuous-infusion, 83% versus bolus-infusion, 78%; P = .24). CONCLUSIONS In survivors of childhood high-risk ALL, continuous-infusion doxorubicin, compared with bolus-infusion, provided no long-term cardioprotection or improvement in ALL event-free survival, hence provided no benefit over bolus-infusion.
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Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL 33101.
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Abstract
Advances in cancer treatment have greatly improved survival rates of children with cancer. However, these same chemotherapeutic or radiologic treatments may result in long-term health consequences. Anthracyclines, chemotherapeutic drugs commonly used to treat children with cancer, are known to be cardiotoxic, but the mechanism by which they induce cardiac damage is still not fully understood. A higher cumulative anthracycline dose and a younger age of diagnosis are only a few of the many risk factors that identify the children at increased risk of developing cardiotoxicity. While cardiotoxicity can develop at anytime, starting from treatment initiation and well into adulthood, identifying the best cardioprotective measures to minimize the long-term damage caused by anthracyclines in children is imperative. Dexrazoxane is the only known agent to date, that is associated with less cardiac dysfunction, without reducing the oncologic efficacy of the anthracycline doxorubicin in children. Given the serious long-term health consequences of cancer treatments on survivors of childhood cancers, it is essential to investigate new approaches to improving the safety of cancer treatments.
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Affiliation(s)
- Danielle Harake
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Vivian I Franco
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jacqueline M Henkel
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tracie L Miller
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
- Holtz Children's Hospital of the University of Miami/Jackson Memorial Medical Center; Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Steven E Lipshultz
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
- Holtz Children's Hospital of the University of Miami/Jackson Memorial Medical Center; Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Lipshultz SE, Mas CM, Henkel JM, Franco VI, Fisher SD, Miller TL. HAART to heart: highly active antiretroviral therapy and the risk of cardiovascular disease in HIV-infected or exposed children and adults. Expert Rev Anti Infect Ther 2012; 10:661-674. [DOI: 10.1586/eri.12.53] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Lipshultz SE, Miller TL, Gerschenson M, Neuberg DS, Stevenson K, Franco VI, Anderson L, LiButti D, Silverman LB, Vrooman LM, Sallan SE. Effect of dexraoxane on impaired mitochondrial structure and function in doxorubicin-treated childhood ALL survivors. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.9530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9530 Background: Cardiotoxicity in doxorubicin (DOX)-treated long-term childhood cancer survivors is characterized by impaired cardiac function which is partly mediated by mitochondrial (mt) energy production. Preclinical studies show irreversible DOX-associated cardiac mt dysfunction. A response to impaired mt function is to increase the mtDNA copies/cell (mtDNA). We examined mtDNA and function in peripheral blood mononuclear cells (PBMCs) in childhood survivors of high-risk ALL who received DOX alone or DOX plus dexrazoxane (DOX/DEX). Methods: Patients with HR ALL treated on DFCI Childhood ALL protocols from 1987-2005 were eligible for this study. PBMCs mtDNA and oxidative phosphorylation (OXPHOS) NADH dehydrogenase (CI) and cytochrome c oxidase (CIV) activities were measured by RT-PCR and immunoassays respectively. A Wilcoxon rank-sum test was used to compare continuous measures between groups. Models for mitochondrial parameters were based on maximum likelihood variance component estimation and were adjusted for patient characteristics. Results: 64 patients provided samples at a median follow-up of 7.8 (2.9-30.2) years. 58% received DOX/DEX. Median cumulative DOX dose was 300 mg/m2. A significant difference was detected between groups for mtDNA (p=0.001, adjusted p=0.015). MtDNA medians for the DOX and DOX/DEX groups were 1106.3 and 310.5. No significant differences were found between groups for CI or CIV activities. Conclusions: DOX-treated survivors have increased mtDNA consistent with impaired mt function, which is abrogated by concurrent use of DEX. The use of DOX/DEX is associated with lower mtDNA. Due to a compensatory increase in mtDNA to augment mt function, overall mt function is not different between groups. This compensatory mechanism in 7.8-year survivors at risk for cardiac dysfunction is concerning over their subsequent lifespan. [Table: see text]
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Affiliation(s)
- Steven E. Lipshultz
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | | | | | | | | | - Lewis B. Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
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27
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B. Diamond M, I. Franco V, L. Miller T, E. Lipshultz S. Preventing and Treating Anthracycline-Related Cardiotoxicity in Survivors of Childhood Cancer. CCTR 2012. [DOI: 10.2174/157339412800675342] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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28
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Franco VI, Henkel JM, Miller TL, Lipshultz SE. Cardiovascular effects in childhood cancer survivors treated with anthracyclines. Cardiol Res Pract 2011; 2011:134679. [PMID: 21331374 PMCID: PMC3038566 DOI: 10.4061/2011/134679] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 12/15/2010] [Indexed: 01/13/2023] Open
Abstract
Anthracyclines are commonly used to treat childhood leukemias and lymphomas, as well as other malignancies, leading to a growing population of long-term childhood cancer survivors. However, their use is limited by cardiotoxicity, increasing survivors' vulnerability to treatment-related complications that can markedly affect their quality of life. Survivors are more likely to suffer from heart failure, coronary artery disease, and cerebrovascular accidents compared to the general population. The specific mechanisms of anthracycline cardiotoxicity are complex and remain unclear. Hence, determining the factors that may increase susceptibility to cardiotoxicity is of great importance, as is monitoring patients during and after treatment. Additionally, treatment and prevention options, such as limiting cumulative dosage, liposomal anthracyclines, and dexrazoxane, continue to be explored. Here, we review the cardiovascular complications associated with the use of anthracyclines in treating malignancies in children and discuss methods for preventing, screening, and treating such complications in childhood cancer survivors.
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Affiliation(s)
- Vivian I. Franco
- Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Miller School of Medicine, Medical Campus-BCRI-D820, 1580 NW 10th Avenue, 5th Floor, Miami, FL 33136, USA
| | - Jacqueline M. Henkel
- Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Miller School of Medicine, Medical Campus-BCRI-D820, 1580 NW 10th Avenue, 5th Floor, Miami, FL 33136, USA
| | - Tracie L. Miller
- Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Miller School of Medicine, Medical Campus-BCRI-D820, 1580 NW 10th Avenue, 5th Floor, Miami, FL 33136, USA
- Holtz Children's Hospital of the University of Miami/Jackson Memorial Medical Center, Sylvester Comprehensive Cancer Center, Miami, FL 33136, USA
| | - Steven E. Lipshultz
- Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Miller School of Medicine, Medical Campus-BCRI-D820, 1580 NW 10th Avenue, 5th Floor, Miami, FL 33136, USA
- Holtz Children's Hospital of the University of Miami/Jackson Memorial Medical Center, Sylvester Comprehensive Cancer Center, Miami, FL 33136, USA
- Department of Pediatrics (D820), University of Miami Miller School of Medicine, P.O. Box 016820, Miami, FL 33101, USA
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Soler-Vilá H, Dubrow R, Franco VI, Kasl SV, Jones BA. The prognostic role of cancer-specific beliefs among prostate cancer survivors. Cancer Causes Control 2010; 22:251-60. [PMID: 21113652 DOI: 10.1007/s10552-010-9693-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 11/08/2010] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The objective of this study is to evaluate the association between cancer-specific beliefs and survival among men newly diagnosed with prostate cancer. METHODS Based on data from a biracial cohort monitored for mortality for up to 15 years, we investigated the association between beliefs and survival among 251 men newly diagnosed with prostate cancer between 1987 and 1990. We examined patients' beliefs related to efficacy of regular checkups for detection, potential negative treatment effects, and perceived curability of cancer. Cox proportional hazards models were adjusted for sociodemographic variables, medical care measures, clinical factors, and lifestyle. RESULTS In a fully adjusted model, not believing that most cancers can be cured was associated with an increased risk of death from any cause (Hazard Ratio = 1.62; 95% confidence interval = 1.11, 2.38). Beliefs regarding the efficacy of checkups or potential negative treatment effects were not associated with survival. CONCLUSIONS Prostate cancer patients who reported not believing that most cancers are curable experienced poorer survival after adjusting for a wide array of prognostic factors and potential confounders. Future research to identify underlying behavioral (medical protocol adherence, lifestyle) and physiological (immune and endocrine regulation) mechanisms of this association would translate into improved intervention strategies for cancer survivors.
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Affiliation(s)
- Hosanna Soler-Vilá
- Department of Epidemiology, Public Health and Sylvester Comprehensive Cancer Center, University of Miami, FL 33136, USA.
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Soler-Vilá H, Dubrow R, Franco VI, Saathoff AK, Kasl SV, Jones BA. Cancer-specific beliefs and survival in nonmetastatic colorectal cancer patients. Cancer 2009; 115:4270-82. [PMID: 19731356 DOI: 10.1002/cncr.24583] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third leading cause of cancer mortality in the United States. Associations between cancer-specific beliefs (beliefs) and survival have been observed among other cancer populations, but similar research in CRC patients is virtually nonexistent, especially in racially diverse populations. The relationship between beliefs and survival was investigated in a cohort of African Americans and non-Hispanic whites with newly diagnosed nonmetastatic CRC, followed for up to 15 years. METHODS The authors analyzed data from a population-based cohort of 286 individuals (115 African Americans and 171 whites, approximately 52% women) diagnosed with nonmetastatic CRC in Connecticut, 1987 to 1991. Cox proportional hazards models were adjusted for sociodemographic (age, sex, race, education, income, occupational status, marital status) and biomedical (stage at diagnosis, histological grade, treatment) variables. RESULTS Not believing in the curability of cancer increased the risk of all-cause mortality (hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.06-2.39) and CRC-specific mortality (HR, 1.65; 95% CI, 0.90-3.03; P=.10). These multivariate estimates were not altered by additional adjustment for insurance coverage, obesity, smoking, alcohol consumption, or comorbidity. Furthermore, the association between perceived curability and survival did not vary significantly by key sociodemographic or biomedical factors. Other beliefs were not associated with survival. CONCLUSIONS Among a racially diverse cohort of men and women with CRC, believing in the curability of cancer was independently associated with survival over a 15-year period. Confirmation of the role of cancer-specific beliefs on survival and study of the potential biobehavioral mechanisms is needed. Findings may inform the design of interventions for cancer survivors.
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Affiliation(s)
- Hosanna Soler-Vilá
- Department of Epidemiology and Public Health, Sylvester Comprehensive Cancer Center, Leonard Miller School of Medicine, University of Miami, Miami, Florida 33136, USA.
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