51
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Rizzo S, De Gaspari M, Basso C. Immune checkpoint inhibitor myocarditis: a call for standardized histopathologic criteria. Eur J Heart Fail 2021; 23:1736-1738. [PMID: 34263962 DOI: 10.1002/ejhf.2303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 12/29/2022] Open
Abstract
Histopathologic criteria for the diagnosis of myocarditis at endomyocardial biopsy: from the Dallas criteria to those recently proposed for immune checkpoint inhibitor (ICI) myocarditis. DCM, dilated cardiomyopathy; DCMI, inflammatory dilated cardiomyopathy; WHF, World Heart Federation.
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Affiliation(s)
- Stefania Rizzo
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Monica De Gaspari
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
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52
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Zou W, Lu J, Hao Y. Myocarditis Induced by Immune Checkpoint Inhibitors: Mechanisms and Therapeutic Prospects. J Inflamm Res 2021; 14:3077-3088. [PMID: 34267536 PMCID: PMC8275200 DOI: 10.2147/jir.s311616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/08/2021] [Indexed: 12/11/2022] Open
Abstract
Under physiological conditions, immune checkpoint molecules downregulate the activation and effector function of myocardial antigen-reactive T cells through an immunosuppressive pathway, thus enabling myocardial T cells to maintain immune homeostasis under the action of central and peripheral tolerance mechanisms. The PD-1/PD-L1 signalling pathway is particularly important for limiting the ability of T cells to attack the heart. Immune checkpoint inhibitors (ICIs) specifically block this PD-1/PD-L1-mediated restriction of T cell activation and other immunosuppressive pathways by targeting immune checkpoints. In recent years, with the wide use of ICIs in cancer treatment, even though the incidence of immunomyocarditis is low, it has attracted increasing attention because of its complex clinical symptoms, rapid progression of disease and high mortality rates. The pathogenesis, genetic susceptibility factors and predictive biomarkers of immunomyocarditis still need to be understood, and multidisciplinary cooperation in the clinical treatment of this complication is necessary.
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Affiliation(s)
- Wenlu Zou
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, 250021, People's Republic of China.,Department of Infectious Disease.,Department of Clinical Laboratory, Shandong University Qilu Hospital, Jinan, Shandong Province, 250012, People's Republic of China
| | - Jie Lu
- Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, 250117, Shandong Province, People's Republic of China
| | - Yan Hao
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong Province, People's Republic of China
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53
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Lehmann LH, Cautela J, Palaskas N, Baik AH, Meijers WC, Allenbach Y, Alexandre J, Rassaf T, Müller OJ, Aras M, Asnani AH, Deswal A, Laufer-Perl M, Thuny F, Kerneis M, Hayek SS, Ederhy S, Salem JE, Moslehi JJ. Clinical Strategy for the Diagnosis and Treatment of Immune Checkpoint Inhibitor-Associated Myocarditis: A Narrative Review. JAMA Cardiol 2021; 6:1329-1337. [PMID: 34232253 DOI: 10.1001/jamacardio.2021.2241] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance In the last decade, immune checkpoint inhibitors (ICIs) have been approved for the treatment of many cancer types. Immune checkpoint inhibitor-associated myocarditis has emerged as a significant and potentially fatal adverse effect. Recognizing, diagnosing, and treating ICI-associated myocarditis poses new challenges for the practicing clinician. Here, the current literature on ICI-associated myocarditis is reviewed. Observations Clinical presentation and cardiac pathological findings are highly variable in patients with ICI-associated myocarditis. Although endomyocardial biopsy is the criterion standard diagnostic test, a combination of clinical suspicion, cardiac biomarkers (specifically troponin), and cardiac imaging, in addition to biopsy, is often needed to support the diagnosis. Importantly, the combination of a cytotoxic T-lymphocyte-associated protein 4 inhibitor with a programmed cell death protein 1 or programmed death-ligand 1 inhibitor increases the risk of developing ICI-associated myocarditis. Conclusion and Relevance This review aims to provide a standardized diagnostic and therapeutic approach for patients with suspected ICI-associated myocarditis. A complete history of recent cancer treatments and physical examination in combination with cardiac biomarkers, cardiac imaging, and endomyocardial biopsy represent a pragmatic diagnostic approach for most cases of ICI-associated myocarditis. The addition of novel biomarkers or imaging modalities is an area of active research and should be evaluated in larger cohorts.
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Affiliation(s)
- Lorenz H Lehmann
- Department of Cardiology, Angiology, and Pneumology, Cardio-Oncology Unit, Heidelberg University Hospital, Heidelberg, Germany.,German Centre for Cardiovascular Research, partner site Heidelberg/Mannheim, Heidelberg, Germany.,German Cancer Research Centre, Heidelberg, Germany
| | - Jennifer Cautela
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, France.,Groupe Méditerranéen de Cardio-Oncologie, Marseille, France.,Oncosafety Network of the Early Phases Cancer Trials Center, Marseille, France
| | - Nicolas Palaskas
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Alan H Baik
- Department of Medicine, Division of Cardiology, University of California, San Francisco
| | - Wouter C Meijers
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France.,Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Association Institut de Myologie, Centre de Recherche en Myologie, UMRS974, Paris, France
| | - Joachim Alexandre
- Department of Pharmacology, Normandie University, University of Caen Normandy, PICARO Cardio-oncology Program, Signalisation, Électrophysiologie et Imagerie des Lésions d'Ischémie-Reperfusion Myocardique, Caen, France
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver J Müller
- Department of Internal Medicine III, University of Kiel, Kiel, Germany.,German Center for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Mandar Aras
- Department of Medicine, Division of Cardiology, University of California, San Francisco
| | - Aarti H Asnani
- CardioVascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anita Deswal
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Michal Laufer-Perl
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Franck Thuny
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, France.,Groupe Méditerranéen de Cardio-Oncologie, Marseille, France
| | - Mathieu Kerneis
- Sorbonne Université, ACTION Study Group, Institut National de la Santé et de la Recherche Médicale, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Stéphane Ederhy
- Hôpitaux Universitaires Paris-Est, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Service de Cardiologie, Unico, Unité de Cardio-Oncologie, Groupe de Recherche Clinique en Cardio-Oncologie, Université Pierre et Marie Curie, Paris, France
| | - Joe-Elie Salem
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, UNICO-GRECO Cardio-Oncology Program, Pitié-Salpêtrière Hospital, Paris, France
| | - Javid J Moslehi
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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54
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Bearse M, Hung YP, Krauson AJ, Bonanno L, Boyraz B, Harris CK, Helland TL, Hilburn CF, Hutchison B, Jobbagy S, Marshall MS, Shepherd DJ, Villalba JA, Delfino I, Mendez-Pena J, Chebib I, Newton-Cheh C, Stone JR. Factors associated with myocardial SARS-CoV-2 infection, myocarditis, and cardiac inflammation in patients with COVID-19. Mod Pathol 2021; 34:1345-1357. [PMID: 33727695 DOI: 10.1038/s41379-021-00790-1] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 02/04/2023]
Abstract
COVID-19 has been associated with cardiac injury and dysfunction. While both myocardial inflammatory cell infiltration and myocarditis with myocyte injury have been reported in patients with fatal COVID-19, clinical-pathologic correlations remain limited. The objective was to determine the relationships between cardiac pathological changes in patients dying from COVID-19 and cardiac infection by SARS-CoV-2, laboratory measurements, clinical features, and treatments. In a retrospective study, 41 consecutive autopsies of patients with fatal COVID-19 were analyzed for the associations between cardiac inflammation, myocarditis, cardiac infection by SARS-CoV-2, clinical features, laboratory measurements, and treatments. Cardiac infection was assessed by in situ hybridization and NanoString transcriptomic profiling. Cardiac infection by SARS-CoV-2 was present in 30/41 cases: virus+ with myocarditis (n = 4), virus+ without myocarditis (n = 26), and virus- without myocarditis (n = 11). In the cases with cardiac infection, SARS-CoV-2+ cells in the myocardium were rare, with a median density of 1 cell/cm2. Virus+ cases showed higher densities of myocardial CD68+ macrophages and CD3+ lymphocytes, as well as more electrocardiographic changes (23/27 vs 4/10; P = 0.01). Myocarditis was more prevalent with IL-6 blockade than with nonbiologic immunosuppression, primarily glucocorticoids (2/3 vs 0/14; P = 0.02). Overall, SARS-CoV-2 cardiac infection was less prevalent in patients treated with nonbiologic immunosuppression (7/14 vs 21/24; P = 0.02). Myocardial macrophage and lymphocyte densities overall were positively correlated with the duration of symptoms but not with underlying comorbidities. In summary, cardiac infection with SARS-CoV-2 is common among patients dying from COVID-19 but often with only rare infected cells. Cardiac infection by SARS-CoV-2 is associated with more cardiac inflammation and electrocardiographic changes. Nonbiologic immunosuppression is associated with lower incidences of myocarditis and cardiac infection by SARS-CoV-2.
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Affiliation(s)
- Mayara Bearse
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Yin P Hung
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Aram J Krauson
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Liana Bonanno
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Baris Boyraz
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Cynthia K Harris
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - T Leif Helland
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Caroline F Hilburn
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Bailey Hutchison
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Soma Jobbagy
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Michael S Marshall
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Daniel J Shepherd
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Julian A Villalba
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | | | - Javier Mendez-Pena
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Ivan Chebib
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Christopher Newton-Cheh
- Cardiovascular Research Center & Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Boston, MA, USA
| | - James R Stone
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA.
- Department of Pathology, Harvard Medical School, Boston, MA, USA.
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55
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Palaskas NL, Segura A, Lelenwa L, Siddiqui BA, Subudhi SK, Lopez-Mattei J, Durand JB, Deswal A, Zhao B, Maximilian Buja L, Iliescu C. Immune checkpoint inhibitor myocarditis: elucidating the spectrum of disease through endomyocardial biopsy. Eur J Heart Fail 2021; 23:1725-1735. [PMID: 34114291 DOI: 10.1002/ejhf.2265] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/17/2021] [Accepted: 06/04/2021] [Indexed: 12/11/2022] Open
Abstract
AIMS Although immune checkpoint inhibitor (ICI) myocarditis carries a high reported mortality, increasing reports of smoldering myocarditis suggest a clinical spectrum of disease. Endomyocardial biopsy (EMB) remains the gold standard for diagnosis of ICI myocarditis, but different pathologic diagnostic criteria exist. The objective of this study was to classify the spectrum of ICI myocarditis and myocardial inflammation by pathology findings on EMB and correlate this with clinical outcomes. METHODS AND RESULTS All patients who had EMB at MD Anderson Cancer Center between January 2018 and August 2019 for suspected ICI myocarditis were retrospectively reviewed. A grading system (Grades 0-2) based on the degree of inflammatory infiltrate was developed by pathologists. Cardiovascular outcomes and treatment were compared between grades of pathology. We identified 28 patients who had EMB for suspected ICI myocarditis, of which 18 were positive for myocarditis/inflammation. There were four deaths (two in Grade 2 and two in Grade 1), but only one was attributable to myocarditis. Grade 2 patients had no myocarditis-associated deaths despite having the highest troponin T values (median 2063 pg/mL). Four patients with Grade 1 myocardial inflammation continued ICI without any immunomodulation, and all were alive without adverse cardiovascular events at follow-up. CONCLUSION We defined an EMB grading system for ICI myocarditis encompassing a spectrum of histologic findings of inflammatory infiltrates. A subset of low-grade myocardial inflammation patients were able to continue ICI without immunosuppressive therapy. Further studies are needed to identify low-risk patients who can be safely treated with ICI.
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Affiliation(s)
- Nicolas L Palaskas
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Laura Lelenwa
- University of Texas Health Science Center, Houston, TX, USA
| | - Bilal A Siddiqui
- Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sumit K Subudhi
- Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan Lopez-Mattei
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean B Durand
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bihong Zhao
- University of Texas Health Science Center, Houston, TX, USA
| | | | - Cezar Iliescu
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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56
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Frayberg M, Yung A, Zubiri L, Zlotoff DA, Reynolds KL. What the Cardiologist Needs to Know About Cancer Immunotherapies and Complications. Curr Treat Options Oncol 2021; 22:53. [PMID: 34037918 DOI: 10.1007/s11864-021-00844-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT Immunotherapies have transformed the current landscape for cancer treatment and demonstrated unparalleled improvements in survival rates. Now, a third of cancer patients are eligible for treatment with the most widely used class of immunotherapy, immune checkpoint inhibitors (ICIs). As more patients are treated with these novel agents, it is critical for both oncologists and subspecialists to establish a better understanding of the adverse events which can occur. The incidence of myocarditis associated with ICI therapy has been reported to be between 0.27 and 1.14%, 5 times that of myocarditis from other cancer therapies, and, of those patients, 20-50% develop a fulminant form. However, because of unclear risk factors, a broad clinical spectrum, and lack of specific noninvasive studies for diagnosis, the care of patients with ICI-associated cardiotoxicity can be challenging. Here, we have provided a brief overview of the current immunotherapy agents with a focus on the emerging evidence regarding diagnosis and management of cardiac adverse events.
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Affiliation(s)
- Marina Frayberg
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anthony Yung
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Leyre Zubiri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel A Zlotoff
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerry L Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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57
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Finke D, Heckmann MB, Salatzki J, Riffel J, Herpel E, Heinzerling LM, Meder B, Völkers M, Müller OJ, Frey N, Katus HA, Leuschner F, Kaya Z, Lehmann LH. Comparative Transcriptomics of Immune Checkpoint Inhibitor Myocarditis Identifies Guanylate Binding Protein 5 and 6 Dysregulation. Cancers (Basel) 2021; 13:2498. [PMID: 34065419 PMCID: PMC8161064 DOI: 10.3390/cancers13102498] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/12/2021] [Accepted: 05/15/2021] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are revolutionizing cancer treatment. Nevertheless, their increasing use leads to an increase of immune-related adverse events (irAEs). Among them, ICI-associated myocarditis (ICIM) is a rare irAE with a high mortality rate. We aimed to characterize the transcriptional changes of ICIM myocardial biopsies and their possible implications. Patients suspected for ICIM were assessed in the cardio-oncology units of University Hospitals Heidelberg and Kiel. Via RNA sequencing of myocardial biopsies, we compared transcriptional changes of ICIM (n = 9) with samples from dilated cardiomyopathy (DCM, n = 11), virus-induced myocarditis (VIM, n = 5), and with samples of patients receiving ICIs without any evidence of myocarditis (n = 4). Patients with ICIM (n = 19) showed an inconsistent clinical presentation, e.g., asymptomatic elevation of cardiac biomarkers (hs-cTnT, NT-proBNP, CK), a drop in left ventricular ejection fraction, or late gadolinium enhancement in cMRI. We found 3784 upregulated genes in ICIM (FDR < 0.05). In the overrepresented pathway 'response to interferon-gamma', we found guanylate binding protein 5 and 6 (compared with VIM: GBP5 (log2 fc 3.21), GBP6 (log2 fc 5.37)) to be significantly increased in ICIM on RNA- and protein-level. We conclude that interferon-gamma and inflammasome-regulating proteins, such as GBP5, may be of unrecognized significance in the pathophysiology of ICIM.
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Affiliation(s)
- Daniel Finke
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- Cardio-Oncology Unit, Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Markus B. Heckmann
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- Cardio-Oncology Unit, Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Janek Salatzki
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Johannes Riffel
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Esther Herpel
- Department of Pathology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Lucie M. Heinzerling
- Department of Dermatology, University Hospital Erlangen, 91054 Erlangen, Germany;
- Deutsches Zentrum Immuntherapie (DZI), University Hospital Erlangen, 91054 Erlangen, Germany
| | - Benjamin Meder
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Mirko Völkers
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Oliver J. Müller
- Department of Cardiology, University Hospital Kiel, 24105 Kiel, Germany;
- German Centre for Cardiovascular Research (DZHK), 24105 Partner Site Kiel/Hamburg/Lübeck, Germany
| | - Norbert Frey
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Hugo A. Katus
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Florian Leuschner
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Ziya Kaya
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
| | - Lorenz H. Lehmann
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.F.); (M.B.H.); (J.S.); (J.R.); (B.M.); (M.V.); (N.F.); (H.A.K.); (F.L.); (Z.K.)
- Cardio-Oncology Unit, Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), 69120 Partner Site Heidelberg/Mannheim, Germany
- Deutsches Krebsforschungszentrum (DKFZ), 69120 Heidelberg, Germany
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58
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Poto R, Marone G, Pirozzi F, Galdiero MR, Cuomo A, Formisano L, Bianco R, Della Corte CM, Morgillo F, Napolitano S, Troiani T, Tocchetti CG, Mercurio V, Varricchi G. How can we manage the cardiac toxicity of immune checkpoint inhibitors? Expert Opin Drug Saf 2021; 20:685-694. [PMID: 33749484 DOI: 10.1080/14740338.2021.1906860] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Cancer immunotherapies with monoclonal antibodies (mAbs) against immune checkpoints (i.e. CTLA-4 and PD-1/PD-L1) have revolutionized antineoplastic treatments. Immune checkpoint inhibitors (ICIs) approved for cancer immunotherapy are mAbs anti-CTLA-4 (ipilimumab), anti-PD-1 (nivolumab, pembrolizumab, and cemiplimab), and anti-PD-L1 (atezolizumab, avelumab, and durvalumab). Treatment with ICIs can be associated with immune-related adverse events (irAEs), including an increased risk of developing myocarditis. These findings are compatible with the observation that, CTLA-4, PD-1, and PD-L1 pathways play a central role in the modulation of autoimmunity.Areas covered: In this paper, we start from examining the pathogenesis of cardiovascular adverse events from ICIs, and then we focus on risk factors and strategies to prevent and manage this cardiotoxicity.Expert opinion: There is a growing need for a multidisciplinary approach of ICI-associated cardiotoxicity, involving oncologists, cardiologists, and immunologists. Prevention and effective management of ICIs cardiotoxicity starts with an in-depth screening and surveillance strategies of high-risk patients, in order to improve early detection and appropriate management in a personalized approach.
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Affiliation(s)
- Remo Poto
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Giancarlo Marone
- Department of Public Health, Section of Hygiene, University of Naples Federico II, Naples, Italy.,Monaldi Hospital Pharmacy, Naples, Italy
| | - Flora Pirozzi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Maria Rosaria Galdiero
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| | - Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Luigi Formisano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.,Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | - Roberto Bianco
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.,Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | | | - Floriana Morgillo
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Stefania Napolitano
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Teresa Troiani
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy.,Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
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Friedrich MG. Immune checkpoint inhibitor cardiotoxicity: what can we learn from real life data on CMR as a diagnostic tool? Eur Heart J 2021; 41:1744-1746. [PMID: 32176277 DOI: 10.1093/eurheartj/ehaa136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Abstract
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Affiliation(s)
- Matthias G Friedrich
- Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Quebec, Canada
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60
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Zhang L, Reynolds KL, Lyon AR, Palaskas N, Neilan TG. The Evolving Immunotherapy Landscape and the Epidemiology, Diagnosis, and Management of Cardiotoxicity: JACC: CardioOncology Primer. JACC CardioOncol 2021; 3:35-47. [PMID: 33842895 PMCID: PMC8034586 DOI: 10.1016/j.jaccao.2020.11.012] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 02/07/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are newer therapies being applied to an increasing number of patients with cancer. Data suggest that up to 36% of cancer patients may be eligible for immunotherapy and, in late 2019, there were more than 3,362 clinical trials initiated to evaluate the effectiveness of immunotherapy, either as single agents or in combination with other immunotherapy, targeted therapies, or traditional cytotoxic or radiation therapy. With the combination of both immune and non-immune treatment approaches, the complexity in making the diagnosis of cardiotoxicity related to an ICI will increase substantially. Here, we summarize the published data on the epidemiology, diagnosis, and management of cardiotoxicity of ICIs. This is a rapidly evolving field, and as our understanding continues to evolve, previously considered hypotheses may not prove to be entirely correct. Research and continued collaborations are urgently needed to provide evidence-based cardiovascular care for this rapidly expanding and vulnerable cohort of patients. (J Am Coll Cardiol CardioOnc 2021;3:35-47) © 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Affiliation(s)
- Lili Zhang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kerry L. Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Massachusetts, USA
| | - Alexander R. Lyon
- Cardio-Oncology Program, Royal Brompton Hospital, London, United Kingdom
- Imperial College London, London, United Kingdom
| | - Nicolas Palaskas
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tomas G. Neilan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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61
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Basso C, Leone O, Rizzo S, De Gaspari M, van der Wal AC, Aubry MC, Bois MC, Lin PT, Maleszewski JJ, Stone JR. Pathological features of COVID-19-associated myocardial injury: a multicentre cardiovascular pathology study. Eur Heart J 2021; 41:3827-3835. [PMID: 32968776 PMCID: PMC7543528 DOI: 10.1093/eurheartj/ehaa664] [Citation(s) in RCA: 347] [Impact Index Per Article: 86.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/17/2020] [Accepted: 07/28/2020] [Indexed: 11/29/2022] Open
Abstract
Aims Coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been associated with cardiovascular features of myocardial involvement including elevated serum troponin levels and acute heart failure with reduced ejection fraction. The cardiac pathological changes in these patients with COVID-19 have yet to be well described. Methods and results In an international multicentre study, cardiac tissue from the autopsies of 21 consecutive COVID-19 patients was assessed by cardiovascular pathologists. The presence of myocarditis, as defined by the presence of multiple foci of inflammation with associated myocyte injury, was determined, and the inflammatory cell composition analysed by immunohistochemistry. Other forms of acute myocyte injury and inflammation were also described, as well as coronary artery, endocardium, and pericardium involvement. Lymphocytic myocarditis was present in 3 (14%) of the cases. In two of these cases, the T lymphocytes were CD4 predominant and in one case the T lymphocytes were CD8 predominant. Increased interstitial macrophage infiltration was present in 18 (86%) of the cases. A mild pericarditis was present in four cases. Acute myocyte injury in the right ventricle, most probably due to strain/overload, was present in four cases. There was a non-significant trend toward higher serum troponin levels in the patients with myocarditis compared with those without myocarditis. Disrupted coronary artery plaques, coronary artery aneurysms, and large pulmonary emboli were not identified. Conclusions In SARS-CoV-2 there are increased interstitial macrophages in a majority of the cases and multifocal lymphocytic myocarditis in a small fraction of the cases. Other forms of myocardial injury are also present in these patients. The macrophage infiltration may reflect underlying diseases rather than COVID-19.
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Affiliation(s)
- Cristina Basso
- Cardiovascular Pathology, Azienda Ospedaliera, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Ornella Leone
- Cardiovascular and Cardiac Transplant Pathology Unit, Department of Pathology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Stefania Rizzo
- Cardiovascular Pathology, Azienda Ospedaliera, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Monica De Gaspari
- Cardiovascular Pathology, Azienda Ospedaliera, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Allard C van der Wal
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Melanie C Bois
- >Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | - Peter T Lin
- >Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - James R Stone
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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62
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Abstract
Purpose of Review Immune checkpoint inhibitors, such as monoclonal antibodies targeting CTLA-4, PD-1, and PD-L1, have improved the outcome of many malignancies, but serious immune-related cardiovascular adverse events have been observed. Patients’ risk factors for these toxicities are currently being investigated. Recent Findings Interfering with the CTLA-4 and PD-1 axes can bring to several immune-related adverse events, including cardiotoxic events such as autoimmune myocarditis, pericarditis, and vasculitis, suggesting that these molecules play an important role in preventing autoimmunity. Summary Risk factors (such as pre-existing cardiovascular conditions, previous and concomitant cardiotoxic treatments, underlying autoimmune diseases, tumor-related factors, simultaneous immune-related toxic effects, and genetic factors) should be always recognized for the correct management of these toxicities.
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63
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Ederhy S, Benhamou-Tarallo I, Chauvet-Droit M, Nhan P, Cohen R, Pinna B, Cholet C, Fenioux C, Champiat S, Salem JE, Soulat-Dufour L, Cohen AA. Cardiotoxicity Related to Immune Checkpoint Inhibitors. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00878-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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64
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Ruddy KJ, Patel SR, Higgins AS, Armenian SH, Herrmann J. Cardiovascular Health during and after Cancer Therapy. Cancers (Basel) 2020; 12:E3737. [PMID: 33322622 PMCID: PMC7763346 DOI: 10.3390/cancers12123737] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 01/22/2023] Open
Abstract
Certain cancer treatments have been linked to specific cardiovascular toxicities, including (but not limited to) cardiomyopathy, atrial fibrillation, arterial hypertension, and myocarditis. Radiation, anthracyclines, human epidermal growth factor receptor 2 (Her2)-directed therapies, fluoropyrimidines, platinums, tyrosine kinase inhibitors and proteasome inhibitors, immune checkpoint inhibitors, and chimeric antigen-presenting (CAR)-T cell therapy can all cause cardiovascular side effects. Management of cardiovascular dysfunction that occurs during cancer therapy often requires temporary or permanent cessation of the risk-potentiating anti-neoplastic drug as well as optimization of medical management from a cardiovascular standpoint. Stem cell or bone marrow transplant recipients face unique cardiovascular challenges, as do patients at extremes of age.
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Affiliation(s)
| | - Shruti R. Patel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | | | - Saro H. Armenian
- Department of Population Sciences, City of Hope, Duarte, CA 91010, USA;
| | - Joerg Herrmann
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN 55905, USA;
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65
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Hang W, Chen C, Seubert JM, Wang DW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther 2020; 5:287. [PMID: 33303763 PMCID: PMC7730152 DOI: 10.1038/s41392-020-00360-y] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/15/2022] Open
Abstract
Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.
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Affiliation(s)
- Weijian Hang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - John M Seubert
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta, Edmonton, Alberta, T6G 2E1, Canada.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Geraud A, Gougis P, Vozy A, Anquetil C, Allenbach Y, Romano E, Funck-Brentano E, Moslehi JJ, Johnson DB, Salem JE. Clinical Pharmacology and Interplay of Immune Checkpoint Agents: A Yin-Yang Balance. Annu Rev Pharmacol Toxicol 2020; 61:85-112. [PMID: 32871087 DOI: 10.1146/annurev-pharmtox-022820-093805] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
T cells have a central role in immune system balance. When activated, they may lead to autoimmune diseases. When too anergic, they contribute to infection spread and cancer proliferation. Immune checkpoint proteins regulate T cell function, including cytotoxic T lymphocyte antigen-4 (CTLA-4) and programmed cell death-1 (PD-1) and its ligand (PD-L1). These nodes of self-tolerance may be exploited pharmacologically to downregulate (CTLA-4 agonists) and activate [CTLA-4 and PD-1/PD-L1 antagonists, also called immune checkpoint inhibitors (ICIs)] the immune system.CTLA-4 agonists are used to treat rheumatologic immune disorders and graft rejection. CTLA-4, PD-1, and PD-L1 antagonists are approved for multiple cancer types and are being investigated for chronic viral infections. Notably, ICIs may be associated with immune-related adverse events (irAEs), which can be highly morbid or fatal. CTLA-4 agonism has been a promising method to reverse such life-threatening irAEs. Herein, we review the clinical pharmacology of these immune checkpoint agents with a focus on their interplay in human diseases.
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Affiliation(s)
- Arthur Geraud
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, CLIP² Galilée, UNICO-GRECO Cardio-oncology Program, and Department of Pharmacology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France; .,Department of Drug Development (DITEP), Gustave Roussy, 94805 Villejuif, France
| | - Paul Gougis
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, CLIP² Galilée, UNICO-GRECO Cardio-oncology Program, and Department of Pharmacology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France;
| | - Aurore Vozy
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, CLIP² Galilée, UNICO-GRECO Cardio-oncology Program, and Department of Pharmacology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France;
| | - Celine Anquetil
- Sorbonne Université, INSERM, Department of Internal Medicine, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France
| | - Yves Allenbach
- Sorbonne Université, INSERM, Department of Internal Medicine, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France
| | - Emanuela Romano
- Center for Cancer Immunotherapy, INSERM U932, Institut Curie, 75248 Paris Cedex 05, France
| | - Elisa Funck-Brentano
- Department of General and Oncologic Dermatology, Ambroise-Paré Hospital, AP-HP, EA 4340, Université Paris-Saclay, 92100 Boulogne-Billancourt, France
| | - Javid J Moslehi
- Department of Medicine, Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
| | - Douglas B Johnson
- Department of Medicine, Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
| | - Joe-Elie Salem
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, CLIP² Galilée, UNICO-GRECO Cardio-oncology Program, and Department of Pharmacology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France; .,Department of Medicine, Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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Waliany S, Lee D, Witteles RM, Neal JW, Nguyen P, Davis MM, Salem JE, Wu SM, Moslehi JJ, Zhu H. Immune Checkpoint Inhibitor Cardiotoxicity: Understanding Basic Mechanisms and Clinical Characteristics and Finding a Cure. Annu Rev Pharmacol Toxicol 2020; 61:113-134. [PMID: 32776859 DOI: 10.1146/annurev-pharmtox-010919-023451] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Immune checkpoint inhibitors (ICIs) attenuate mechanisms of self-tolerance in the immune system, enabling T cell responses to cancerous tissues and revolutionizing care for cancer patients. However, by loweringbarriers against self-reactivity, ICIs often result in varying degrees of autoimmunity. Cardiovascular complications, particularly myocarditis but also arrhythmias, pericarditis, and vasculitis, have emerged as significant complications associated with ICIs. In this review, we examine the clinical aspects and basic science principles that underlie ICI-associated myocarditis and other cardiovascular toxicities. In addition, we discuss current therapeutic approaches. We believe a better mechanistic understanding of ICI-associated toxicities can lead to improved patient outcomes by reducing treatment-related morbidity.
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Affiliation(s)
- Sarah Waliany
- Department of Medicine, Stanford University, Stanford, California 94305, USA;
| | - Daniel Lee
- Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA
| | - Ronald M Witteles
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Joel W Neal
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Division of Oncology, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Patricia Nguyen
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA.,Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Mark M Davis
- Department of Microbiology and Immunology and Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, California 94305, USA.,Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Joe-Elie Salem
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, CLIP² Galilée, UNICO-GRECO Cardio-Oncology Program, and Department of Pharmacology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France.,Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA; .,Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA
| | - Sean M Wu
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA.,Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Javid J Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA; .,Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA
| | - Han Zhu
- Department of Medicine, Stanford University, Stanford, California 94305, USA; .,Stanford Cardiovascular Institute, Stanford University, Stanford, California 94305, USA.,Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
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Cassol CA, Owen D, Kendra K, Braga JR, Frankel WL, Arnold CA. Programmed cell death-1 (PD-1) and programmed death-ligand 1 (PD-L1) expression in PD-1 inhibitor-associated colitis and its mimics. Histopathology 2020; 77:240-249. [PMID: 32298485 DOI: 10.1111/his.14115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/17/2022]
Abstract
AIMS Immune checkpoint inhibitors (ICIs) have revolutionised the treatment of advanced malignancies by boosting immune-mediated destruction of neoplastic cells, but are associated with side effects stemming from generalised immune system activation against normal tissues. Checkpoint ligand expression in non-tumoral cells of tissues affected by immune-related adverse effects has been described in ICI-associated hypophysitis, myocarditis, and acute interstitial nephritis. We aimed to investigate the tissue expression of the immune checkpoint receptor programmed cell death-1 (PD-1) and its ligand, programmed death-ligand 1 (PD-L1), in PD-1 inhibitor-associated colitis (PD1i colitis). METHODS AND RESULTS PD-1 and PD-L1 immunohistochemical expression levels were analysed in 15 cases of PD1i colitis and potential mimics-infectious colitis and inflammatory bowel disease (IBD). Increased epithelial expression of PD-L1 was observed in PD1i colitis as compared with normal colon and infectious colitis, but the expression level was lower than that in IBD. Conversely, PD-1 expression in inflammatory cells was higher in infectious colitis, intermediate in IBD, and minimal or absent in normal colon and in patients receiving PD-1 inhibitors. CONCLUSIONS Although our results do not justify the use of PD-L1 as a discriminatory marker of PD1i colitis against other entities within the differential diagnosis, they support the concept that PD1i colitis and IBD have similar pathogenetic mechanisms. They also highlight the fact that PD-L1 epithelial overexpression is a commonly used mechanism of the gastrointestinal tract mucosa to protect itself from inflammatory-mediated damage resulting from different aetiologies, which probably underpins the high incidence of gastrointestinal immune-related adverse effects in patients receiving ICI therapies, in whom this mechanism is disrupted.
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Affiliation(s)
- Clarissa A Cassol
- Department of Pathology, Division of Medical Oncology, Ohio State University, Columbus, OH, USA
| | - Dwight Owen
- Department of Internal Medicine, Division of Medical Oncology, Ohio State University, Columbus, OH, USA
| | - Kari Kendra
- Department of Internal Medicine, Division of Medical Oncology, Ohio State University, Columbus, OH, USA
| | - Juarez R Braga
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Wendy L Frankel
- Department of Pathology, Division of Medical Oncology, Ohio State University, Columbus, OH, USA
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Michel L, Totzeck M, Lehmann L, Finke D. Emerging role of immune checkpoint inhibitors and their relevance for the cardiovascular system. Herz 2020; 45:645-651. [DOI: 10.1007/s00059-020-04954-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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70
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Targeting Negative and Positive Immune Checkpoints with Monoclonal Antibodies in Therapy of Cancer. Cancers (Basel) 2019; 11:cancers11111756. [PMID: 31717326 PMCID: PMC6895894 DOI: 10.3390/cancers11111756] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 02/06/2023] Open
Abstract
The immune checkpoints are regulatory molecules that maintain immune homeostasis in physiological conditions. By sending T cells a series of co-stimulatory or co-inhibitory signals via receptors, immune checkpoints can both protect healthy tissues from adaptive immune response and activate lymphocytes to remove pathogens effectively. However, due to their mode of action, suppressive immune checkpoints may serve as unwanted protection for cancer cells. To restore the functioning of the immune system and make the patient’s immune cells able to recognize and destroy tumors, monoclonal antibodies are broadly used in cancer immunotherapy to block the suppressive or to stimulate the positive immune checkpoints. In this review, we aim to present the current state of application of monoclonal antibodies in clinics, used either as single agents or in a combined treatment. We discuss the limitations of these therapies and possible problem-solving with combined treatment approaches involving both non-biological and biological agents. We also highlight the most promising strategies based on the use of monoclonal or bispecific antibodies targeted on immune checkpoints other than currently implemented in clinics.
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