Cardiotoxicity of Anti-Cancer Radiation Therapy: a Focus on Heart Failure

Linggui Zhugan decoction ameliorating mitochondrial damage of doxorubicin-induced cardiotoxicity by modulating the AMPK-FOXO3a pathway targeting BTG2

BACKGROUND

Doxorubicin (DOX), a widely used anthracycline chemotherapy agent, is effective against various malignant tumors. However, its clinical application is significantly limited due to dose-dependent cardiotoxicity. Linggui Zhugan Decoction (LGZGD), a traditional Chinese medicine formulation, has demonstrated notable cardioprotective effects. However, its potential to mitigate DOX-induced cardiotoxicity (DIC) remains unexplored.

OBJECTIVE

This study investigated the protective effects of LGZGD against DIC and explores its ability to enhance mitochondrial function by modulating the AMPK-FOXO3a pathway via targeting BTG2.

METHODS

A zebrafish DIC model was established to evaluate the cardioprotective effects of LGZGD on embryos and adults. Further investigations included in vitro studies with H9c2 cells and in vivo experiments using mouse models to assess LGZGD's pharmacological actions and their impact on mitochondrial function. Network pharmacology and transcriptomic analyses were performed to predict the potential mechanism of LGZGD in regulating the AMPK-FOXO3a pathway via BTG2. Verification was conducted through molecular docking, molecular dynamics (MD) simulations, and immunofluorescence co-localization.

RESULTS

LGZGD enhanced survival rates and alleviated heart tissue damage in zebrafish. In vitro, LGZGD reduced DOX-induced reactive oxygen species (ROS) production in H9c2 cells, decreased apoptosis, improved mitochondrial membrane potential, and preserved mitochondrial function. In vivo, LGZGD improved cardiac function and prevented myocardial structural damage in mice. Additionally, it mitigated oxidative stress, inflammation, and apoptosis while reversing DOX-induced mitochondrial structural damage. Network pharmacology and transcriptomic analyses suggested that LGZGD regulates the BTG2 gene and AMPK-FOXO3a pathway activity. Molecular docking, MDs, and immunofluorescence co-localization supported the hypothesis that LGZGD modulates the AMPK-FOXO3a pathway by targeting BTG2.

CONCLUSION

LGZGD exerts significant cardioprotective effects against DIC by reducing oxidative stress, inflammation, and apoptosis preserving while mitochondrial structure and function. These findings offer a novel insight into LGZGD's clinical relevance in DIC management. Targeting BTG2 to regulate the AMPK-FOXO3a pathway highlights LGZGD as a promising therapeutic strategy for preventing and treating DIC.

Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Curcumin Nanoparticles-related Non-invasive Tumor Therapy, and Cardiotoxicity Relieve

Non-invasive antitumor therapy can treat tumor patients who cannot tolerate surgery or are unsuitable. However, tumor resistance to non-invasive antitumor therapy and cardiotoxicity caused by treatment seriously affect the quality of life and prognosis of patients. As a kind of polyphenol extracted from herbs, curcumin has many pharmacological effects, such as anti-inflammation, antioxidation, antitumor, etc. Curcumin plays the antitumor effect by directly promoting tumor cell death and reducing tumor cells' invasive ability. Curcumin exerts the therapeutic effect mainly by inhibiting the nuclear factor-κB (NF-κB) signal pathway, inhibiting the production of cyclooxygenase-2 (COX-2), promoting the expression of caspase-9, and directly inducing reactive oxygen species (ROS) production in tumor cells. Curcumin nanoparticles can solve curcumin's shortcomings, such as poor water solubility and high metabolic rate, and can be effectively used in antitumor therapy. Curcumin nanoparticles can improve the prognosis and quality of life of tumor patients by using as adjuvants to enhance the sensitivity of tumors to non-invasive therapy and reduce the side effects, especially cardiotoxicity. In this paper, we collect and analyze the literature of relevant databases. It is pointed out that future research on curcumin tends to alleviate the adverse reactions caused by treatment, which is of more significance to tumor patients.

Development and first implementation of a novel multi-modality cardiac motion and dosimetry phantom for radiotherapy applications

BACKGROUND

Cardiac applications in radiation therapy are rapidly expanding including magnetic resonance guided radiation therapy (MRgRT) for real-time gating for targeting and avoidance near the heart or treating ventricular tachycardia (VT).

PURPOSE

This work describes the development and implementation of a novel multi-modality and magnetic resonance (MR)-compatible cardiac phantom.

METHODS

The patient-informed 3D model was derived from manual contouring of a contrast-enhanced Coronary Computed Tomography Angiography scan, exported as a Stereolithography model, then post-processed to simulate female heart with an average volume. The model was 3D-printed using Elastic50A to provide MR contrast to water background. Two rigid acrylic modules containing cardiac structures were designed and assembled, retrofitting to an MR-safe programmable motor to supply cardiac and respiratory motion in superior-inferior directions. One module contained a cavity for an ion chamber (IC), and the other was equipped with multiple interchangeable cavities for plastic scintillation detectors (PSDs). Images were acquired on a 0.35 T MR-linac for validation of phantom geometry, motion, and simulated online treatment planning and delivery. Three motion profiles were prescribed: patient-derived cardiac (sine waveform, 4.3 mm peak-to-peak, 60 beats/min), respiratory (cos4 waveform, 30 mm peak-to-peak, 12 breaths/min), and a superposition of cardiac (sine waveform, 4 mm peak-to-peak, 70 beats/min) and respiratory (cos4 waveform, 24 mm peak-to-peak, 12 breaths/min). The amplitude of the motion profiles was evaluated from sagittal cine images at eight frames/s with a resolution of 2.4 mm × 2.4 mm. Gated dosimetry experiments were performed using the two module configurations for calculating dose relative to stationary. A CT-based VT treatment plan was delivered twice under cone-beam CT guidance and cumulative stationary doses to multi-point PSDs were evaluated.

RESULTS

No artifacts were observed on any images acquired during phantom operation. Phantom excursions measured 49.3 ± 25.8%/66.9 ± 14.0%, 97.0 ± 2.2%/96.4 ± 1.7%, and 90.4 ± 4.8%/89.3 ± 3.5% of prescription for cardiac, respiratory, and cardio-respiratory motion profiles for the 2-chamber (PSD) and 12-substructure (IC) phantom modules respectively. In the gated experiments, the cumulative dose was <2% from expected using the IC module. Real-time dose measured for the PSDs at 10 Hz acquisition rate demonstrated the ability to detect the dosimetric consequences of cardiac, respiratory, and cardio-respiratory motion when sampling of different locations during a single delivery, and the stability of our phantom dosimetric results over repeated cycles for the high dose and high gradient regions. For the VT delivery, high dose PSD was <1% from expected (5-6 cGy deviation of 5.9 Gy/fraction) and high gradient/low dose regions had deviations <3.6% (6.3 cGy less than expected 1.73 Gy/fraction).

CONCLUSIONS

A novel multi-modality modular heart phantom was designed, constructed, and used for gated radiotherapy experiments on a 0.35 T MR-linac. Our phantom was capable of mimicking cardiac, cardio-respiratory, and respiratory motion while performing dosimetric evaluations of gated procedures using IC and PSD configurations. Time-resolved PSDs with small sensitive volumes appear promising for low-amplitude/high-frequency motion and multi-point data acquisition for advanced dosimetric capabilities. Illustrating VT planning and delivery further expands our phantom to address the unmet needs of cardiac applications in radiotherapy.

Use of Polygenic Risk Score for Prediction of Heart Failure in Cancer Survivors

Background

The risk for heart failure (HF) is increased among cancer survivors, but predicting individual HF risk is difficult. Polygenic risk scores (PRS) for HF prediction summarize the combined effects of multiple genetic variants specific to the individual.

Objectives

The aim of this study was to compare clinical HF prediction models with PRS in both cancer and noncancer populations.

Methods

Cancer and HF diagnoses were identified using International Classification of Diseases-10th Revision codes. HF risk was calculated using the ARIC (Atherosclerosis Risk in Communities) HF score (ARIC-HF). The PRS for HF (PRS-HF) was calculated according to the Global Biobank Meta-analysis Initiative. The predictive performance of the ARIC-HF and PRS-HF was compared using the area under the curve (AUC) in both cancer and noncancer populations.

Results

After excluding 2,644 participants with HF prior to consent, 440,813 participants without cancer (mean age 57 years, 53% women) and 43,720 cancer survivors (mean age 60 years, 65% women) were identified at baseline. Both the ARIC-HF and PRS-HF were significant predictors of incident HF after adjustment for chronic kidney disease, overall health rating, and total cholesterol. The PRS-HF performed poorly in predicting HF among cancer (AUC: 0.552; 95% CI: 0.539-0.564) and noncancer (AUC: 0.561; 95% CI: 0.556-0.566) populations. However, the ARIC-HF predicted incident HF in the noncancer population (AUC: 0.804; 95% CI: 0.800-0.808) and provided acceptable performance among cancer survivors (AUC: 0.748; 95% CI: 0.737-0.758).

Conclusions

The prediction of HF on the basis of conventional risk factors using the ARIC-HF score is superior compared to the PRS, in cancer survivors, and especially among the noncancer population.

Cardiac PET Imaging of ATP Binding Cassette (ABC) Transporters: Opportunities and Challenges

Adenosine triphosphate binding cassette (ABC) transporters are a broad family of membrane protein complexes that use energy to transport molecules across cells and/or intracellular organelle lipid membranes. Many drugs used to treat cardiac diseases have an affinity for these transporters. Among others, P-glycoprotein (P-gp) plays an essential role in regulating drug concentrations that reach cardiac tissue and therefore contribute to cardiotoxicity. As a molecular imaging modality, positron emission tomography (PET) has emerged as a viable technique to investigate the function of P-gp in organs and tissues. Using PET imaging to evaluate cardiac P-gp function provides new insights for drug development and improves the precise use of medications. Nevertheless, information in this field is limited. In this review, we aim to examine the current applications of ABC transporter PET imaging and its tracers in the heart, with a specific emphasis on P-gp. Furthermore, the opportunities and challenges in this novel field will be discussed.