Troponin-T and myoglobin plus echocardiographic evaluation for monitoring early cardiotoxicity of weekly epirubicin–paclitaxel in metastatic breast cancer patients

Cardiovascular Biomarkers in Cardio-Oncology: Antineoplastic Drug Cardiotoxicity and Beyond

Serum biomarkers represent a reproducible, sensitive, minimally invasive and inexpensive method to explore possible adverse cardiovascular effects of antineoplastic treatments. They are useful tools in risk stratification, the early detection of cardiotoxicity and the follow-up and prognostic assessment of cancer patients. In this literature review, we aim at describing the current state of knowledge on the meaning and the usefulness of cardiovascular biomarkers in patients with cancer; analyzing the intricate relationship between cancer and cardiovascular disease (especially HF) and how this affects cardiovascular and tumor biomarkers; exploring the role of cardiovascular biomarkers in the risk stratification and in the identification of chemotherapy-induced cardiotoxicity; and providing a summary of the novel potential biomarkers in this clinical setting.

The Value of Troponin as a Biomarker of Chemotherapy-Induced Cardiotoxicity

In cancer survivors, cardiac dysfunction is the main cause of mortality. Cardiotoxicity represents a decline in cardiac function associated with cancer therapy, and the risk factors include smoking, dyslipidemia, an age of over 60 years, obesity, and a history of coronary artery disease, diabetes, atrial fibrillation, or heart failure. Troponin is a biomarker that is widely used in the detection of acute coronary syndromes. It has a high specificity, although it is not exclusively associated with myocardial ischemia. The aim of this paper is to summarize published studies and to establish the role of troponin assays in the diagnosis of cardiotoxicity associated with various chemotherapeutic agents. Troponin has been shown to be a significant biomarker in the diagnosis of the cardiac dysfunction associated with several types of chemotherapeutic drugs: anthracyclines, anti-human epidermal growth factor receptor 2 treatment, and anti-vascular endothelial growth factor therapy. Based on the data available at this moment, troponin is useful for baseline risk assessment, the diagnosis of cardiotoxicity, and as a guide for the initiation of cardioprotective treatment. There are currently clear regulations regarding the timing of troponin surveillance depending on the patient’s risk of cardiotoxicity and the type of medication administered, but data on the cut-off values of this biomarker are still under investigation.

Troponin as a cardiotoxicity marker in breast cancer patients receiving anthracycline-based chemotherapy: A narrative review

The approach to breast cancer has changed in recent decades due to significant advances in screening, early diagnosis, and treatment; however, the risk of cardiovascular injury induced by chemotherapy has remained similar. Anthracyclines are the most common agents used in breast cancer treatment and may lead to cardiotoxicity, which appears to have a direct relationship with accumulated dose and duration of treatment. Therefore, the use of cardiac biomarkers derived from those used in cardiac disease diagnosis has been applied to the early identification, evaluation, and cardiotoxicity monitoring during chemotherapy. Cardiac troponins (cTn) have high specificities and high sensitivity in myocardial injury and are used in the diagnosis and risk stratification of acute coronary syndromes. cTn have been validated by clinical studies in the cardiotoxicity diagnosis and prognosis in patients treated with high doses of anthracyclines alone or in combination, mainly with trastuzumab. Thus, the identification of cardiotoxicity through cTn in the preclinical phase would be crucial for the application of preventive strategies. Here, we analyzed 23 cross-sectional, prospective and retrospective studies using cTn as the biomarker of cardiotoxicity in patients with breast cancer receiving treatment with anthracyclines. Studies showed that the association of cTn with different biomarkers can contribute to the early diagnosis of cardiotoxicity; however the main evidence is that low cTn levels is related to a better outcome with a good negative predictive value (NPV). In conclusion, different studies are still necessary for the adoption of cTn as a routine clinical biomarker in patients with breast cancer receiving anthracycline treatment.

The impact of paclitaxel and carboplatin chemotherapy on the autonomous nervous system of patients with ovarian cancer

Background

Paclitaxel-based regimens are frequently associated with the development of peripheral neuropathy. The autonomous nervous system (ANS) effects, however, of this chemotherapeutic agent remain unexplored.

Methods

We investigated a group of 31 female patients with ovarian cancer receiving treatment with paclitaxel and carboplatin, as well as a group of 16 healthy age- and gender-matched healthy volunteers. All study participants completed a questionnaire and were assessed neurophysiologically at three time points (baseline, 3–4 months and 6–8 months following the onset of chemotherapy). The evaluation of the ANS included assessment of the adrenergic cardiovascular function (orthostatic hypotension-OH), parasympathetic heart innervation (30/15 ratio) and sympathetic skin response (SSR).

Results

At the 3–4 months ANS assessment, 19.2 % of the patients had systolic OH and the same percentage had diastolic OH, but at the 6–8 months evaluation no patient had systolic OH and only 13.8 % had diastolic OH. The values of the 30/15 ratio were significantly reduced at both time points, whereas the SSR was not affected.

Conclusions

Combined paclitaxel and carboplatin chemotherapy is associated with significant effects on the parasympathetic heart innervation and occasionally with effects on the adrenergic cardiovascular reaction. The SSR remained unaffected. Physicians should be alert to the possibility of these treatment-emergent side effects, so as to monitor ANS parameters and introduce treatment modifications accordingly. Our findings however, should be validated in larger cohorts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0710-4) contains supplementary material, which is available to authorized users.

Anthracycline-Induced Cardiomyopathy in Adults

Anthracyclines are one of the most commonly used antineoplastic agent classes, and a core part of the treatment in breast cancers, hematological malignancies, and sarcomas. Their benefit is decreased by their well-recognized cardiotoxicity. The purpose of this review is to outline the presentation, mechanisms, diagnosis, and treatment of anthracyclines-induced cardiotoxicity. Symptomatic heart failure occurs in 2% to 5% of patients treated with anthrayclines and may be higher in older patients or patients with cardiovascular risk factors. The mechanisms involved in anthracycline-induced cardiotoxicity involve myocyte loss by apoptosis in the presence of a limited regenerative capacity. Once symptomatic, anthracycline-induced cardiotoxicity is associated with markedly decreased survival. Left ventricular ejection fraction (LVEF), mostly determined using echocardiography, is used to monitor patients treated with anthracyclines. As more than 1/3 of patients treated with anthracyclines do not recover their baseline LVEF once it is decreased, more sensitive echocardiographic indices of LV function such as myocardial deformation or biomarkers have been studied in patients monitoring. Cardioprotective treatments such as angiotensin-converting enzyme inhibitors, beta-blockers, iron chelators, statins, and metformin are also the topic of research efforts.

Anthracycline or trastuzumab-related cardiotoxicity: do we have a predictive biomarker?

Chemotherapy-induced cardiotoxicity, is a well-known and potentially serious complication strongly impacting the quality of life and overall survival of breast cancer patients. The current diagnostic approach to detect cardiac damage is the estimation of left ventricular ejection fraction by echocardiography. However, this approach exhibits less sensitivity toward early prediction of cardiomyopathy, not allowing for preventive strategies. Measurement of serum cardiac-specific biomarkers can be a valid diagnostic tool for identifying patients prone to developing cardiotoxocity and in whom closer cardiac monitoring and preventive strategies are pivotal. In this article, we review work done on biomarkers in recent years, with an emphasis on troponin and B-type natriuretic peptide, which are currently the most studied in this field. We also briefly discuss current and emerging imaging techniques for early detection of cardiomyopathy.

Exercise Prevention of Cardiovascular Disease in Breast Cancer Survivors

Thanks to increasingly effective treatment, breast cancer mortality rates have significantly declined over the past few decades. Following the increase in life expectancy of women diagnosed with breast cancer, it has been recognized that these women are at an elevated risk for cardiovascular disease due in part to the cardiotoxic side effects of treatment. This paper reviews evidence for the role of exercise in prevention of cardiovascular toxicity associated with chemotherapy used in breast cancer, and in modifying cardiovascular risk factors in breast cancer survivors. There is growing evidence indicating that the primary mechanism for this protective effect appears to be improved antioxidant capacity in the heart and vasculature and subsequent reduction of treatment-related oxidative stress in these structures. Further clinical research is needed to determine whether exercise is a feasible and effective nonpharmacological treatment to reduce cardiovascular morbidity and mortality in breast cancer survivors, to identify the cancer therapies for which it is effective, and to determine the optimal exercise dose. Safe and noninvasive measures that are sensitive to changes in cardiovascular function are required to answer these questions in patient populations. Cardiac strain, endothelial function, and cardiac biomarkers are suggested outcome measures for clinical research in this field.

Cardiac troponin T for early detection of cardiotoxicity in breast cancer patients treated with epirubicin

The aim of the study was to investigate the role of cTnT for the prediction of long term cardiac dysfunction after epirubicin-containing adjuvant chemotherapy for breast cancer. The study group comprised of 45 patients (all female; mean age 48 ±8 years), treated with epirubicin-containing adjuvant chemotherapy for stage 2 and stage 3 breast cancer. Patients received either 4 cycles of cyclophosphamide plus epirubicin (90 mg/m2) (n=23; stage 2 breast cancer) or 6 cycles of cyclophosphamide plus epirubicin (75 mg/m2) plus fluorouracil (n=18; stage 3 breast cancer). Venous blood samples were drawn, before and 72 hours after, every cycle of chemotherapy for the measurement of cTnT. Cardiac assessment was carried out at baseline and 1 year after chemotherapy by clinical evaluation, electrocardiography, radio-nuclide ventriculography (RNV) and transthoracic echocardiography. All patients remained free of clinical heart failure during the study period. In 26 patients (63%), cTnT was elevated after chemotherapy. Mean left ventricular ejection fraction, assessed by RNV at baseline and one year after chemotherapy, were 61±8% and 56±7% (p<0.0001). The sensitivity and specifity of cTnT for the detection of left ventricular systolic dysfunction at one year were 69% and 39% respectively. Echocardiographic examinations at baseline and one year after chemotherapy revealed a significant decrease in E/A ratio from 1.15±0.3 to 0.9±0.2 in cTnT positive patients, suggesting diastolic dysfunction. In conclusion, elevated serum cTnT levels after epirubicin-containing adjuvant chemotherapy for stage 2 and stage 3 breast cancer, predict future cardiac dysfunction with moderate sensitivity and poor specificity.

Trastuzumab plus weekly epirubicin and paclitaxel for locally advanced and metastatic breast cancer: preliminary results of a feasibility-phase II study aimed at cardiotoxicity

A feasibility-phase II study was conducted to assess the cardiotoxicity of weekly trastuzumab, epirubicin, and paclitaxel in patients with human epidermal growth factor receptor-2-positive metastatic breast cancer. Untreated patients with human epidermal growth factor receptor-2-positive advanced breast cancer received trastuzumab (day 1), and epirubicin (25 mg/m2) and paclitaxel (80 mg/m2) (day 2) on a weekly basis. The rate of patients with left-ventricular ejection fraction (L-VEF) reduction greater than 10% after 12 weeks was the primary end point. According to a two-stage model, an initial step with 15 patients was required; after 11 patients without toxicity, a second step with 21 patients was planned. After 255 courses in 15 patients (median treatment weeks: 18), the relative dose intensity was 94.7%. At 12 weeks, three patients (20%) displayed a L-VEF reduction greater than 10%, six and six (40%) patients showed a L-VEF reduction < or =10% or no change, respectively. Baseline, -12 weeks, and -24 weeks median L-VEF was 69% (range 61-77), 65% (range 60-76), and 65% (range 55-73), respectively. No EKG/cardiac signs were present. Thirteen patients had grade 3 alopecia and two patients had grade 3 asthenia, in the absence of severe hematological toxicity. Objective responses were observed in 11 patients (73.3%, 95% confidence interval 51.0-95.7), with 10 partial. The weekly administration of trastuzumab-epirubicin-paclitaxel is extremely tolerable, also with regard to L-VEF reduction. These results allowed entrance to the second step of the study.

Expert opinion on the use of anthracyclines in patients with advanced breast cancer at cardiac risk

Anthracyclines are considered to be among the most active agents for the treatment of breast cancer. However, their use is limited by cumulative, dose-related cardiotoxicity. Such cardiotoxicity results in a permanent loss of cardiac myocytes and a progressive reduction in cardiac function following each subsequent dose of anthracycline. Initially, damage to the heart is subclinical; however, increasingly impaired cardiac function can result in cardiovascular symptoms, with serious cardiac injury resulting in chronic heart failure. Since the early detection and treatment of cardiotoxicity can reduce its clinical effects, it is important that oncologists are aware of these adverse effects and manage them appropriately. This review examines the risk factors for anthracycline-associated cardiotoxicity and offers recommendations on strategies to reduce the cardiotoxicity of anthracyclines in the management of patients with advanced breast cancer.

Combined NT-pro-BNP and CW-Doppler ultrasound cardiac output monitoring (USCOM) in epirubicin and liposomal doxorubicin therapy

BACKGROUND

Chemotherapy with epirubicin is approved in women with breast cancer and is associated with a certain degree of cardiotoxicity.

HYPOTHESIS

Epirubicin changes stroke volume, cardiac output and systemic vascular resistance, while liposomal doxorubicin does not.

METHODS

75 patients with HER-2-positive metastatic breast cancer were continuously measured with CW-Doppler ultrasound for stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR) before, during and after drug infusion in combination with NT-pro-BNP before and 10 min after drug infusion.

RESULTS

Epirubicin infusion increased stroke volume significantly in low-level NT-pro-BNP (62+/-23 ml vs. 74+/-29 ml, p=0.004) and high-level NT-pro-BNP (48+/-5 ml vs. 64+/-20 ml, p=0.131), while liposomal doxorubicin infusion increased stroke volume significantly in low-level NT-pro-BNP (54+/-16 ml vs. 67+/-22 ml, p=0.001) and high-level NT-pro-BNP (65+/-22 ml vs. 82+/-27 ml, p=0.001). Cardiac output was significantly increased in epirubicin (p=0.004) by 20% (NT-pro-BNP<125 pg/ml) and not significantly 38% (NT-pro-BNP>125 pg/ml; p=0.144), while in liposomal doxorubicin cardiac output was significantly increased by 23% (NT-pro-BNP<125 pg/ml; p=0.023) and 33% (NT-pro-BNP>125 pg/ml; p=0.001). In liposomal doxorubicin cardiac index was significantly increased by 26% (NT-pro-BNP<125 pg/ml; p=0.021) and 33% (NT-pro-BNP>125 pg/ml; p=0.0001). SVR was significantly reduced during and after epirubicin therapy.

CONCLUSION

Using the CW-Doppler USCOM a different hemodynamic response to epirubicin vs. liposomal doxorubicin is evident. Epirubicin leads to a significant upregulation of stroke volume and cardiac output, which is even more pronounced in the high-level NT-pro-BNP group, while liposomal doxorubicin does not change immediate hemodynamics. No deterioration of cardiac function using the real-time CW-Doppler ultrasound USCOM or an increase in NT-pro-BNP levels was evident during epirubicin or liposomal doxorubicin therapy.