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Zheng Y, Chen Z, Song W, Xu Y, Zhao Z, Sun Y, Wang Y, Geng X, Zhao J, Zhang X, Xu Y, Chan JSK, Tse G, Li G, Hong L, Liu T. Cardiovascular adverse events associated with immune checkpoint inhibitors: A retrospective multicenter cohort study. Cancer Med 2024; 13:e7233. [PMID: 38752474 PMCID: PMC11097245 DOI: 10.1002/cam4.7233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 04/16/2024] [Accepted: 04/20/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Over the past decade, immune checkpoint inhibitors (ICIs) have significantly transformed cancer treatment. However, ICIs inevitably may cause a spectrum of immune-related adverse events, among which cardiovascular toxicity, particularly myocarditis, while infrequent, has garnered increasing attention due to its high fatality rate. METHODS We conducted a multicenter retrospective study to characterize ICI-associated cardiovascular adverse events. Logistic regression was performed to explore the risk factors for the development of myocarditis and severe myocarditis. Receiver operating characteristic curves were conducted to assess the diagnostic abilities of cardiac biomarkers to distinguish different cardiovascular toxicities, and the performance and calibration were evaluated using Hosmer-Lemeshow test. RESULTS Forty-four patients were identified, including thirty-five myocarditis, five heart failure, three arrhythmias, and one myocardial infarction. Compared with other patients, myocarditis patients had higher cardiac troponin-I (cTnI) levels (p < 0.001), higher creatine kinase levels (p = 0.003), higher creatine kinase isoenzyme-MB (CK-MB) levels (p = 0.013), and shorter time to the incidence of adverse cardiovascular events (p = 0.022) after ICI treatment. Twenty-one patients (60%) were classified as severe myocarditis, and they presented higher cardiac troponin I (cTnI) levels (p = 0.013), higher N-terminal pro-B-type natriuretic peptide levels (p = 0.031), higher creatine kinase levels (p = 0.018), higher CK-MB levels (p = 0.026), and higher neutrophil to lymphocyte ratio (NLR) levels (p = 0.016) compared to non-severe myocarditis patients after ICI treatment. Multivariate logistic regression showed that CK-MB (adjusted odds ratio [OR]: 1.775, 95% confidence interval [CI]: 1.055-2.984, p = 0.031) was the independent risk factor of the development of ICI-associated myocarditis, and cTnI (adjusted OR: 1.021, 95% CI: 1.002-1.039, p = 0.03) and NLR (adjusted OR: 1.890, 95% CI: 1.026-3.483, p = 0.041) were the independent risk factors of ICI-associated severe myocarditis. The receiver operating characteristic curve showed an area under curve of 0.785 (95% CI: 0.642 to 0.928, p = 0.013) for CK-MB, 0.765 (95% CI: 0.601 to 0.929, p = 0.013) for cTnI, and 0.773 for NLR (95% CI: 0.597 to 0.948, p = 0.016). CONCLUSIONS Elevated CK-MB after ICI treatment is the independent risk factor for the incidence of ICI-associated myocarditis, and elevated cTnI and NLR after ICI treatment are the independent risk factors for the development of ICI-associated severe myocarditis. CK-MB, cTnI, and NLR demonstrated a promising predictive utility for the identification of ICI-associated myocarditis and severe myocarditis.
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Affiliation(s)
- Yi Zheng
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Ziliang Chen
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Wenhua Song
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Yu Xu
- Department of OncologyTianjin Huanghe HospitalTianjinChina
| | - Zhiqiang Zhao
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Yihong Sun
- Department of CardiologyChina‐Japan Friendship HospitalBeijingChina
| | - Yuanyuan Wang
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Xuhong Geng
- Department of FunctionFourth Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Jun Zhao
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Xiaowei Zhang
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Yanmin Xu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | | | - Gary Tse
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
- School of Nursing and Health StudiesHong Kong Metropolitan UniversityHong KongChina
- Cardiac Electrophysiology Unit, Cardiovascular Analytics GroupPowerHealth LimitedHong KongChina
| | - Guangping Li
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Lili Hong
- Department of OncologyTianjin Huanghe HospitalTianjinChina
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
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Jayan A, Mammen AL, Suarez-Almazor ME. Immune Checkpoint Inhibitor-induced Myositis. Rheum Dis Clin North Am 2024; 50:281-290. [PMID: 38670726 DOI: 10.1016/j.rdc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Myositis induced by immune checkpoint inhibitors (ICIs) is an infrequent, potentially fatal, immune-related adverse event. It has higher incidence in patients who receive combination ICI therapy compared to monotherapy. Patients can present with clinical manifestation symptoms of myositis alone or in combination with myocarditis and/or myasthenia gravis, which significantly worsens the course and prognosis. Diagnosis can generally be made on the basis of clinical presentation, elevation of muscle enzymes, and electromyographic changes, but some patients may require a muscle biopsy. The first line of therapy is high-dose corticosteroids, followed by immunosuppression, plasmapheresis, or intravenous immunoglobulin in patients with severe disease.
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Affiliation(s)
- Athira Jayan
- Department of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Andrew L Mammen
- Department of Neurology, Johns Hopkins University School of Medicine; Department of Medicine, Johns Hopkins University School of Medicine; Muscle Disease Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 50, Room 1146, Bethesda, MD 20892, USA
| | - Maria E Suarez-Almazor
- Department of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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An Y, Xue L, Xu L, Zhang C, Yang Y, Liu Y, Ma N. Evaluation the Effect of Anthracyclines on Cardiac Function in Children Lymphoma Survivors by Left Ventricular Myocardial Work. Pediatr Cardiol 2024:10.1007/s00246-024-03480-2. [PMID: 38662212 DOI: 10.1007/s00246-024-03480-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 03/20/2024] [Indexed: 04/26/2024]
Abstract
Anthracycline chemotherapy is associated with the left ventricular (LV) dysfunction, but the conventional echocardiographic parameter is insensitive in detecting subclinical cardiac dysfunction, and the role of echocardiography in children cancer survivors (CCSs) has not been well established. Here, the myocardial work (MW) was employed to evaluate the early effect of the anthracyclines on LV function in children lymphoma survivors, as well as to explore the clinical application value of this modality. 51 children lymphoma survivors treated with anthracyclines were included. During the treatments, the echocardiography was performed at baseline (T0 phase), the 3rd (T1 phase) and 6th (T2 phase) chemotherapeutic cycle, respectively. After that, the conventional echocardiographic parameters, LV global longitudinal strain (GLS), and global myocardial work (GMW) parameters were obtained. Finally, these echocardiographic parameters were compared to distinguish the differences among three groups, and correlation analysis was used to identify relationship between GMW parameters and LV GLS. Compared with the baseline, we found that there are no significant differences for LVEF and other conventional echocardiographic parameters after chemotherapy, but the value of LV lateral E/E' increased at T1 and T2 group. The GLS, global work index, global constructed work, and global work efficiency were decreased, while the global wasted work was increased after chemotherapy (all P < 0.05). The correlation analysis showed that the GLS has significant correlation with GMW parameters (all P < 0.001). The MW, as a new noninvasive echocardiography modality, could be used to quantitatively evaluate the LV MW in children lymphoma survivors treated with anthracyclines, which providing a sensitive method to early detect the children's LV dysfunction after the chemotherapy.
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Affiliation(s)
- Yuqiong An
- Heart Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Li Xue
- Heart Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Liyuan Xu
- Heart Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Chao Zhang
- Heart Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Yijie Yang
- Heart Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Yong Liu
- Department of Ultrasound, Beijing-Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Ning Ma
- Heart Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.
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Gao P, Li X, He Z, Zhang H, Zhang Z, Liu Z. Lethal Immune Myocarditis and Myasthenia Gravis Due to Anti-PD-1 Treatment for a Bladder Cancer Patient: A Case Report and Possible Treatment Inspiration. Int Med Case Rep J 2024; 17:359-365. [PMID: 38651079 PMCID: PMC11034559 DOI: 10.2147/imcrj.s449525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/04/2024] [Indexed: 04/25/2024] Open
Abstract
Immune checkpoint inhibitors (ICI) have become a new hope for many patients with advanced cancer by blocking tumor immune escape. Bladder cancer is a common malignant tumor of the urinary tract epithelium that often relapses and metastasizes after surgery, chemotherapy, and radiotherapy. Immunotherapy has dramatically improved patient survival rates and clinical benefits as a new, potentially effective therapy. However, avoidance of various immune-related adverse events (irAEs) remains an implausible idea. ICI-induced myocarditis is different from viral myocarditis, and mortality is still high with the current treatment. We report the case of an 82-year-old female patient with ICI-induced fulminant myocarditis and myasthenia gravis. Although she actively accepted the current mainstream treatment for immune-related myocarditis and myasthenia, she died of heart and respiratory failure. Analyzing and reporting the patient's disease development process and the changes in related indicators may help peers gain a deeper understanding of immune-related adverse events and reduce the mortality of immune-related myocarditis.
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Affiliation(s)
- Pan Gao
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Xinyu Li
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Ziqiu He
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Hongbo Zhang
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Zhi Zhang
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
| | - Zonglai Liu
- Department of Urology, Second People’s Hospital of Yichang, Yichang, Hubei Province, People’s Republic of China
- Department of Urology, Second People’s Hospital of China Three Gorges University, Yichang, Hubei Province, People’s Republic of China
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Fabiani I, Chianca M, Aimo A, Emdin M, Dent S, Fedele A, Cipolla CM, Cardinale DM. Use of new and emerging cancer drugs: what the cardiologist needs to know. Eur Heart J 2024:ehae161. [PMID: 38591670 DOI: 10.1093/eurheartj/ehae161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 04/10/2024] Open
Abstract
The last decade has witnessed a paradigm shift in cancer therapy, from non-specific cytotoxic chemotherapies to agents targeting specific molecular mechanisms. Nonetheless, cardiovascular toxicity of cancer therapies remains an important concern. This is particularly relevant given the significant improvement in survival of solid and haematological cancers achieved in the last decades. Cardio-oncology is a subspecialty of medicine focusing on the identification and prevention of cancer therapy-related cardiovascular toxicity (CTR-CVT). This review will examine the new definition of CTR-CVT and guiding principles for baseline cardiovascular assessment and risk stratification before cancer therapy, providing take-home messages for non-specialized cardiologists.
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Affiliation(s)
- Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
| | - Michela Chianca
- Interdisciplinary Center for Health Science, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Alberto Aimo
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
- Interdisciplinary Center for Health Science, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Michele Emdin
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
- Interdisciplinary Center for Health Science, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Susan Dent
- Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Antonella Fedele
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Carlo Maria Cipolla
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Daniela Maria Cardinale
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
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Vicino A, Hottinger AF, Latifyan S, Boughdad S, Becce F, Prior JO, Kuntzer T, Brouland JP, Dunet V, Obeid M, Théaudin M. Immune checkpoint inhibitor-related myositis and myocarditis: diagnostic pitfalls and imaging contribution in a real-world, institutional case series. J Neurol 2024; 271:1947-1958. [PMID: 38141128 PMCID: PMC10973051 DOI: 10.1007/s00415-023-12134-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/03/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are reshaping the prognosis of many cancers, but often cause immune-related adverse events (irAEs). Among neurological irAEs, myositis is the most frequently reported. Our aim is to describe clinical and non-clinical characteristics, treatment and outcome of all irMyositis (skeletal limb-girdle and/or ocular myositis) and irMyocarditis cases in our reference center. METHODS We retrospectively enrolled all irMyositis/irMyocarditis patients seen between 2018 and 2022. We reviewed demographics, clinical characteristics, biological, neurophysiological, imaging workup, treatment and outcome. RESULTS We included 14 consecutive patients. The most frequent treatments were pembrolizumab (35%) or ipilimumab-nivolumab combination (35%). Limb-girdle, ocular (non-fluctuating palpebral ptosis and/or diplopia with or without ophthalmoparesis) and cardiac phenotypes were equally distributed, overlapping in 40% of cases. Ocular involvement was frequently misdiagnosed; review of brain MRIs disclosed initially missed signs of skeletal myositis in one patient and ocular myositis in 3. Seven patients had other co-existing irAEs. When performed, myography showed a myogenic pattern. CK was elevated in 8/15 patients, troponin-T in 12/12 and troponin-I in 7/9 tested patients. ICI were discontinued in all cases, with further immunosuppressive treatment in nine patients. In most cases, neurological and cardiological outcome was good at last follow-up. CONCLUSION Myositis is a potentially severe irAE. Despite its heterogeneous presentation, some highly suggestive clinical symptoms, such as ocular involvement, or radiological signs should raise physicians' attention to avoid misdiagnosis. We thus recommend a multidisciplinary assessment (including complete neuromuscular evaluation) even in case of isolated myocarditis. Our series underlines the importance of an early diagnosis, since suspension of ICI and adequate treatment are usually associated with good functional outcome.
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Affiliation(s)
- Alex Vicino
- Nerve-Muscle Unit, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Andreas F Hottinger
- Lundin Family Brain Tumor Center, Departments of Oncology and Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sofiya Latifyan
- Department of Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sarah Boughdad
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John O Prior
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thierry Kuntzer
- Nerve-Muscle Unit, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Philippe Brouland
- Pathology Institute, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michel Obeid
- Immunology and Allergy Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Marie Théaudin
- Nerve-Muscle Unit, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Li Z, Zhao R, Wang C, Wang Y, Lin J, Zhao S, Chen J, Zhou Y, Liu T, Wang F, Shu X, Zeng M, Cheng L. Cardiac magnetic resonance-based layer-specific strain in immune checkpoint inhibitor-associated myocarditis. ESC Heart Fail 2024; 11:1061-1075. [PMID: 38243390 DOI: 10.1002/ehf2.14664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/10/2023] [Accepted: 12/18/2023] [Indexed: 01/21/2024] Open
Abstract
AIMS To assess the different imaging characteristics between corticosteroid-sensitive (CS) and corticosteroid-refractory (CR) immune checkpoint inhibitor-associated myocarditis (ICIaM) with cardiac magnetic resonance (CMR) and the potential CMR parameters in the early detection of CR ICIaM. METHODS AND RESULTS Thirty-five patients diagnosed with ICIaM and 30 age and gender-matched cancer patients without a history of ICI treatment were enrolled. CMR with contrast was performed within 2 days of clinical suspicion. Left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE) were assessed by CMR. LV sub-endocardial (GLSendo) and sub-epicardial (GLSepi) global longitudinal strains were quantified by offline feature tracking analysis. CS and CR ICIaM were defined based on the trend of Troponin I and clinical course during corticosteroid treatment. All 35 patients presented with non-fulminant symptoms upon initial assessment. Twenty patients (57.14%) were sensitive, and 15 (42.86%) were refractory to corticosteroids. Compared with controls, 22 patients (62.86%) with ICIaM developed LGE. LVEF decreased in CR ICIaM compared with the CS group and controls. GLSendo (-14.61 ± 2.67 vs. -18.50 ± 2.53, P < 0.001) and GLSepi (-14.75 ± 2.53 vs. -16.68 ± 2.05, P < 0.001) significantly increased in patients with CR ICIaM compared with the CS ICIaM. In patients with CS ICIaM, although GLSepi (-16.68 ± 2.05 vs. -19.31 ± 1.80, P < 0.001) was impaired compared with the controls, GLSendo was preserved. There was no difference in CMR parameters between LGE-positive and negative groups. LVEF, GLSendo, and GLSepi were predictors of CR ICIaM. When LVEF, GLSendo, and GLSepi were included in multivariate analysis, only GLSendo remained an independent predictor of CR ICIaM (OR: 2.170, 95% CI: 1.189-3.962, P = 0.012). A GLSendo of ≥-17.10% (sensitivity, 86.7%; specificity, 80.0%; AUC, 0.860; P < 0.001) could predict CR ICIaM in the ICIaM cohort. Kaplan-Meier analysis showed that in patients with impaired GLSendo of ≥-17.10%, cardiovascular adverse events (CAEs) occurred much earlier than in patients with preserved GLSendo of <-17.10% (Log-rank test P = 0.017). CONCLUSIONS CR and CS ICIaM demonstrated different functional and morphological characteristics in different myocardial layers. An impaired GLSendo could be a helpful parameter in early identifying corticosteroid-refractory individuals in the ICIaM population.
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Affiliation(s)
- Zheng Li
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Rui Zhao
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Cong Wang
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yan Wang
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinyi Lin
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shihai Zhao
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiahui Chen
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuhong Zhou
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianshu Liu
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Wang
- Department of Medical Oncology, Qinhuai Medical Area of General Hospital of Eastern Theater Command, Nanjing, China
| | - Xianhong Shu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Mengsu Zeng
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Leilei Cheng
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
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Zhang Q, Yuan J, Zhao W, Ouyang W, Chen B, Li Y, Tao J, Chen X, Li G, Guo Z, Liu Y. Coxsackie B virus-induced myocarditis in a patient with a history of lymphoma: A case report and review of literature. Medicine (Baltimore) 2024; 103:e37248. [PMID: 38457543 PMCID: PMC10919497 DOI: 10.1097/md.0000000000037248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/23/2024] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION In rare occasions, coxsackievirus infections can cause serious illness, such as encephalitis and myocarditis. The immunotherapies of cancer could increase the risk of myocarditis, especially when applying immune checkpoint inhibitors. Herein, we report a rare case of Coxsackie B virus-induced myocarditis in a patient with a history of lymphoma. CASE PRESENTATION A 32-year-old woman was admitted to the hospital with recurrent fever for more than 20 days, and she had a history of lymphoma. Before admission, the positron emission tomography/computed tomography result indicated that the patient had no tumor progression, and she was not considered the cancer-related fever upon arriving at our hospital. Patient's red blood cell, platelet count, and blood pressure were decreased. In addition, she had sinus bradycardia and 3 branch blocks, which was consistent with acute high lateral and anterior wall myocardial infarction. During hospitalization, the patient had recurrent arrhythmia, repeated sweating, poor mentation, dyspnea, and Coxsackie B virus were detected in patient's blood samples by pathogen-targeted next-generation sequencing. The creatine kinase, creatine kinase MB, and N-terminal pro-brain natriuretic peptide were persistently elevated. Consequently, the patient was diagnosed with viral myocarditis induced by Coxsackie B virus, and treated with acyclovir, gamma globulin combined with methylprednisolone shock therapy, trimetazidine, levosimendan, sildenan, continuous pump pressors with m-hydroxylamine, entecavir, adefovir, glutathione, pantoprazole, and low-molecular-weight heparin. Her symptoms worsened and died. CONCLUSION We reported a case with a history of lymphoma presented with fever, myocardial injury, who was ultimately diagnosed with Coxsackie B virus-induced myocarditis. Moreover, pathogen-targeted next-generation sequencing indeed exhibited higher sensitivity compared to mNGS in detecting Coxsackie B virus.
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Affiliation(s)
- Qian Zhang
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jia Yuan
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Wei Zhao
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Weiwei Ouyang
- Department of Oncology, The Affiliated Hospital of Guizhou Medical University and The Affiliated Cancer Hospital of Guizhou Medical University, Guiyang, China
| | - Bowen Chen
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Yehong Li
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Junling Tao
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Xianjun Chen
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Guangsu Li
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Zhendong Guo
- Beijing Goldstandard Medicine Independent Clinical Laboratory Co. Ltd., Beijing, China
| | - Ying Liu
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
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9
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Zhuang Y, An Q, Wang F, Han D, Qiao Z, Jiang Q, Liu M, Li Y, Shangguan J, Bi X, Shen D. The role of circulating biomarkers in predicting the 30-day mortality of immune checkpoint inhibitors-related myocarditis: a retrospective cohort study. Intern Emerg Med 2024; 19:377-389. [PMID: 38085435 DOI: 10.1007/s11739-023-03481-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 07/13/2023] [Accepted: 11/07/2023] [Indexed: 03/21/2024]
Abstract
Immune checkpoint inhibitors-related myocarditis (ICIs-M) is a rare and highly lethal immune-related adverse events (irAEs) in common irAEs. This study aims to find circulating biomarkers that can reflect disease state and prognosis accurately. 48 patients with ICIs-M were enrolled according to the diagnostic criteria for ICIs-related myocarditis. For all enrolled patients, valuable information was extracted retrospectively from the medical system, mainly including demographic information, tumor information and laboratory examination. The follow-up period was defined as 30 days after the first diagnosis of ICIs-M. In this study, the 30-day mortality rate of ICIs-M was 24.4%. After adjusting for potential confounding factors using multivariate analysis tools, we demonstrated the excellent performance of biomarkers in predicting 30-day mortality in patients with ICIs-M, including PLT (hazard ratio (HR), 1.07; 95% confidence interval (95%CI), 1.01-1.14; p = 0.028), ALT (HR, 1.23; 95%CI, 1.06-1.41; p = 0.005), AST(HR, 1.06; 95%CI, 1.01-1.10; p = 0.015), LDH (HR, 1.15; 95%CI, 1.04-1.26; p = 0.004), troponin I(HR, 1.44; 95%CI, 1.09-1.89; p = 0.009), PLR (blood plate/lymphocyte) (HR, 1.04; 95% CI, 1.01-1.07; p = 0.024), LAR (lactate dehydrogenase/albumin) (HR, 1.05; 95%CI, 1.01-1.09; p = 0.012), and AAR (aspartate transaminase/albumin) (HR, 1.18; 95%CI, 1.00-1.39; p = 0.048). The analysis of the receiver operating characteristic showed that biomarkers with area under curve (AUC) greater than or equal to 0.80 were LDH (cutoff value, 724.5; AUC, 0.86; 95%CI, 0.75-0.97), LAR (cutoff value, 18.11; AUC, 0.87; 95%CI, 0.76-0.97), troponin I (cutoff value, 0.87; AUC, 0.80; 95%CI, 0.62-0.99), and AAR(cutoff value, 1.52; AUC, 0.80; 95%CI, 0.61-0.98). LDH, LAR, troponin I, and AAR are a group of promising biomarkers that demonstrate excellent predictive ability in predicting the 30-day mortality rate of immune-related myocarditis.
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Affiliation(s)
- Yuansong Zhuang
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Quanxu An
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Fuhang Wang
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dongjian Han
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Zhentao Qiao
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Qingjiao Jiang
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Miaomiao Liu
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yuhang Li
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Jiahong Shangguan
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xuanye Bi
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Deliang Shen
- Cardiology Department, Key Laboratory of Cardiac Injury and Repair of Henan Province, First Affiliated Hospital of Zhengzhou University, Henan, China.
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10
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He Y, Yu H, Dai S, He M, Ma L, Xu Z, Luo F, Wang L. Immune checkpoint inhibitors break whose heart? Perspectives from cardio-immuno-oncology. Genes Dis 2024; 11:807-818. [PMID: 37692505 PMCID: PMC10491874 DOI: 10.1016/j.gendis.2023.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/12/2023] [Indexed: 03/30/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibody antagonists, which can block cytotoxic T lymphocyte antigen-4 (CTLA-4), programmed death-1/ligand-1 (PD-1/PD-L1) pathways, and other molecules exploited by tumor cells to evade T cell-mediated immune response. ICIs have transformed the treatment landscape for various cancers due to their amazing efficacy. Many anti-tumor therapies, including targeted therapy, radiotherapy, and chemotherapy, combine ICIs to make the treatment more effective. However, the off-target immune activation caused by ICIs may lead to a broad spectrum of immune-related adverse events (irAEs) affecting multiple organ systems. Among irAEs, cardiotoxicity induced by ICIs, uncommon but fatal, has greatly offset survival benefits from ICIs, which is heartbreaking for both patients and clinicians. Consequently, such cardiotoxicity requires special vigilance, and it has become a common challenge both for patients and clinicians. This article reviewed the clinical manifestations and influence of cardiotoxicity from the view of patients and clinicians, elaborated on the underlying mechanisms in conjunction with animal studies, and then attempted to propose management strategies from a cardio-immuno-oncology multidisciplinary perspective.
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Affiliation(s)
- Yingying He
- Oncology Department, Deyang People's Hospital, Deyang, Sichuan 618000, China
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Hui Yu
- Cardiovascular Department, Mianyang Central Hospital, Mianyang, Sichuan 621000, China
| | - Shuang Dai
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Miao He
- Oncology Department, Deyang People's Hospital, Deyang, Sichuan 618000, China
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Ling Ma
- Department of Rheumatology and Immunology, Deyang People's Hospital, Deyang, Sichuan 618000, China
| | - Zihan Xu
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Feng Luo
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
| | - Li Wang
- Department of Medical Oncology, Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China
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11
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Saad R, Ghaddar A, Zeenny RM. Pembrolizumab-induced myocarditis with complete atrioventricular block and concomitant myositis in a metastatic bladder cancer patient: a case report and review of the literature. J Med Case Rep 2024; 18:107. [PMID: 38383436 PMCID: PMC10882824 DOI: 10.1186/s13256-024-04397-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/19/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND The cardiovascular system is among the least systems affected by immune-related adverse events. We report a rare life-threatening case of pembrolizumab-induced myocarditis with complete atrioventricular block and concomitant myositis in a metastatic bladder cancer patient. CASE PRESENTATION An 82-year-old Caucasian female with invasive urothelial carcinoma, started on first-line pembrolizumab, was admitted four days after receiving her second dose for severe asthenia, diffuse muscle aches, neck pain, and lethargy. In the emergency department, she had several episodes of bradycardia reaching 40 beats per minute associated with general discomfort and fatigue. Electrocardiography showed a third-degree atrioventricular heart block, while the patient remained normotensive. Cardiac damage parameters were altered with elevated levels of creatine phosphokinase of 8930 U/L, suggestive of immune checkpoint inhibitor-induced myositis, and troponin T of 1.060 ng/mL. Transthoracic echocardiography showed a preserved ejection fraction. Pembrolizumab-induced myocarditis was suspected. Therefore, treatment was initiated with high-dose glucocorticoids for 5 days, followed by a long oral steroid taper. A pacemaker was also implanted. Treatment resulted in the resolution of heart block and a decrease in creatine phosphokinase to the normal range. CONCLUSION Life-threatening cardiac adverse events in the form of myocarditis may occur with pembrolizumab use, warranting vigilant cardiac monitoring. Troponin monitoring in high-risk patients, along with baseline echocardiography may help identify this complication promptly to prevent life-threatening consequences.
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Affiliation(s)
- R Saad
- Department of Pharmacy, American University of Beirut Medical Center, Riad El-Solh, P.O. Box 11-0236, Beirut, 1107 2020, Lebanon
| | - A Ghaddar
- Department of Pharmacy, American University of Beirut Medical Center, Riad El-Solh, P.O. Box 11-0236, Beirut, 1107 2020, Lebanon
| | - R M Zeenny
- Department of Pharmacy, American University of Beirut Medical Center, Riad El-Solh, P.O. Box 11-0236, Beirut, 1107 2020, Lebanon.
- INSPECT-LB (Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie-Liban), Beirut, Lebanon.
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12
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Murtagh G, deFilippi C, Zhao Q, Barac A. Circulating biomarkers in the diagnosis and prognosis of immune checkpoint inhibitor-related myocarditis: time for a risk-based approach. Front Cardiovasc Med 2024; 11:1350585. [PMID: 38410245 PMCID: PMC10894940 DOI: 10.3389/fcvm.2024.1350585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 02/28/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that block immune checkpoints and therefore activate immune cells, allowing them to recognize and attack cancer cells. ICIs have revolutionized oncology practice, but their use has been complicated by immune-related adverse events (irAEs). Of cardiovascular (CV) irAEs, ICI-related myocarditis has received significant attention due to high mortality rates, ranging from 25% to 50%, despite its overall low incidence. Establishing the early diagnosis of ICI-myocarditis is important for early initiation of steroids and consideration of hospitalization in patients who are at risk for hemodynamic compromise and need high acuity care in a tertiary setting. In this review, we summarize the diagnostic and prognostic tools for ICI-myocarditis, including electrocardiography, echocardiography, cardiac magnetic resonance imaging, with emphasis on circulating biomarkers. Cardiac troponins (cTns) are an essential component of the diagnosis of ICI-myocarditis, and we provide a summary of the recent studies that utilized different assays (cTnI vs. cTnT) and outcomes (diagnosis vs. prognosis including major adverse cardiac outcomes). With the exponential increase in ICI use across different oncology indications, there is a major need to include biomarkers in risk stratification to guide diagnosis and treatment. Our review proposes a framework for future multisite registries, including cTn evaluation at baseline and at the time of irAE suspicion, with development of central biobanking to allow head-to-head evaluation and clinical validation of different biomarker assays in ICI-myocarditis. This approach, with the inclusion of CV biomarkers into clinical and pragmatic oncology trials, holds promise to improve the early recognition and management of ICI-myocarditis and CV irAEs, thus leading to better outcomes.
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Affiliation(s)
- Gillian Murtagh
- Core Diagnostics, Abbott Laboratories, Abbott Park, IL, United States
| | | | - Qiong Zhao
- Inova Schar Heart and Vascular, Falls Church, VA, United States
| | - Ana Barac
- Inova Schar Heart and Vascular, Falls Church, VA, United States
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13
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Yan T, Yu L, Zhang J, Chen Y, Fu Y, Tang J, Liao D. Achilles' Heel of currently approved immune checkpoint inhibitors: immune related adverse events. Front Immunol 2024; 15:1292122. [PMID: 38410506 PMCID: PMC10895024 DOI: 10.3389/fimmu.2024.1292122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/04/2024] [Indexed: 02/28/2024] Open
Abstract
Immunotherapy has revolutionized the cancer treatment landscape by opening up novel avenues for intervention. As the use of immune checkpoint inhibitors (ICIs) has exponentially increased, so have immune-related adverse events (irAEs). The mechanism of irAEs may involve the direct damage caused by monoclonal antibodies and a sequence of immune responses triggered by T cell activation. Common side effects include dermatologic toxicity, endocrine toxicity, gastrointestinal toxicity, and hepatic toxicity. While relatively rare, neurotoxicity, cardiotoxicity, and pulmonary toxicity can be fatal. These toxicities pose a clinical dilemma regarding treatment discontinuation since they can result in severe complications and necessitate frequent hospitalization. Vigilant monitoring of irAEs is vital in clinical practice, and the principal therapeutic strategy entails the administration of oral or intravenous glucocorticoids (GSCs). It may be necessary to temporarily or permanently discontinue the use of ICIs in severe cases. Given that irAEs can impact multiple organs and require diverse treatment approaches, the involvement of a multidisciplinary team of experts is imperative. This review aims to comprehensively examine the pathogenesis, clinical manifestations, incidence, and treatment options for various irAEs.
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Affiliation(s)
- Ting Yan
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Lun Yu
- Department of Positron Emission Tomography–Computed Tomography (PET-CT) Center, Chenzhou No. 1 People’s Hospital, Chenzhou, China
| | - Jiwen Zhang
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
- School of Pharmacy, University of South China, Hengyang, China
| | - Yun Chen
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Yilan Fu
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Jingyi Tang
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Dehua Liao
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
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14
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Achim A, Liblik K, Gevaert S. Immune checkpoint inhibitors - the revolutionary cancer immunotherapy comes with a cardiotoxic price. Trends Cardiovasc Med 2024; 34:71-77. [PMID: 36152788 DOI: 10.1016/j.tcm.2022.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/06/2022] [Accepted: 09/19/2022] [Indexed: 12/17/2022]
Abstract
The development of immune checkpoint inhibitors (ICIs) has provided a novel and revolutionary treatment option for previously incurable cancers. However, this major advancement is accompanied by a spectrum of cardiotoxic adverse events that are uncommon but potentially fatal. The oncologic indications of ICIs are becoming increasingly complex, requiring robust clinical monitoring to assess for cardiovascular complications. This is reflected in the recent introduction of the first cardio-oncology guidelines, a sign of the cardiovascular community's recognition that seeks to match this dynamic. The aim of this review is to summarize the cardiac side effects of ICI, with an emphasis on prevalence, diagnosis, and treatment options.
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Affiliation(s)
- Alexandru Achim
- Klinik für Kardiologie, Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Switzerland; "Niculae Stancioiu" Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania.
| | - Kiera Liblik
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
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15
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Daetwyler E, Wallrabenstein T, König D, Cappelli LC, Naidoo J, Zippelius A, Läubli H. Corticosteroid-resistant immune-related adverse events: a systematic review. J Immunother Cancer 2024; 12:e007409. [PMID: 38233099 PMCID: PMC10806650 DOI: 10.1136/jitc-2023-007409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 01/19/2024] Open
Abstract
Immune checkpoint inhibitor (ICI) treatment has become an important therapeutic option for various cancer types. Although the treatment is effective, ICI can overstimulate the patient's immune system, leading to potentially severe immune-related adverse events (irAEs), including hepatitis, colitis, pneumonitis and myocarditis. The initial mainstay of treatments includes the administration of corticosteroids. There is little evidence how to treat steroid-resistant (sr) irAEs. It is mainly based on small case series or single case reports. This systematic review summarizes available evidence about sr-irAEs. We conducted a systematic literature search in PubMed. Additionally, we included European Society for Medical Oncology, Society for Immunotherapy of Cancer, National Comprehensive Cancer Network and American Society of Clinical Oncology Guidelines for irAEs in our assessment. The study population of all selected publications had to include patients with cancer who developed hepatitis, colitis, pneumonitis or myocarditis during or after an immunotherapy treatment and for whom corticosteroid therapy was not sufficient. Our literature search was not restricted to any specific cancer diagnosis. Case reports were also included. There is limited data regarding life-threatening sr-irAEs of colon/liver/lung/heart and the majority of publications are single case reports. Most publications investigated sr colitis (n=26), followed by hepatitis (n=21), pneumonitis (n=17) and myocarditis (n=15). There is most data for mycophenolate mofetil (MMF) to treat sr hepatitis and for infliximab, followed by vedolizumab, to treat sr colitis. Regarding sr pneumonitis there is most data for MMF and intravenous immunoglobulins (IVIG) while data regarding infliximab are conflicting. In sr myocarditis, most evidence is available for the use of abatacept or anti-thymocyte globulin (ATG) (both with or without MMF) or ruxolitinib with abatacept. This review highlights the need for prompt recognition and treatment of sr hepatitis, colitis, pneumonitis and myocarditis. Guideline recommendations for sr situations are not defined precisely. Based on our search, we recommend-as first line treatment-(1) MMF for sr hepatitis, (2) infliximab for sr colitis, followed by vedolizumab, (3) MMF and IVIG for sr pneumonitis and (4) abatacept or ATG (both with or without MMF) or ruxolitinib with abatacept for sr myocarditis. These additional immunosuppressive agents should be initiated promptly if there is no sufficient response to corticosteroids within 3 days.
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Affiliation(s)
- Eveline Daetwyler
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Till Wallrabenstein
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Division of Hematology and Medical Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - David König
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Laura C Cappelli
- Divison of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Alfred Zippelius
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Heinz Läubli
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
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16
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Pineton de Chambrun M, Marquet Y, Kerneis M, Schmidt M, Luyt CE, Combes A, Hekimian G. Authors reply in response to a letter on: "Diagnostic yield, safety and therapeutic consequences of myocardial biopsy in clinically suspected fulminant myocarditis unweanable from mechanical circulatory support". Ann Intensive Care 2024; 14:3. [PMID: 38183591 PMCID: PMC10771393 DOI: 10.1186/s13613-023-01237-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/08/2024] Open
Affiliation(s)
- Marc Pineton de Chambrun
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France.
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, F-75013, Paris, France.
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut E3M, Paris, France.
- Sorbonne Université, Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France.
| | - Yann Marquet
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Mathieu Kerneis
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, F-75013, Paris, France
- ACTION Study Group, Département de Cardiologie, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, F-75013, Paris, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, F-75013, Paris, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, F-75013, Paris, France
| | - Guillaume Hekimian
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
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17
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Gul R, Shehryar M, Mahboob A, Kareem HK, Inayat A, Safi D, Kamran A. Immune Checkpoint Inhibitor-Associated Myocarditis: A Literature Review. Cureus 2024; 16:e52952. [PMID: 38406102 PMCID: PMC10894055 DOI: 10.7759/cureus.52952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
Recently in the field of oncology, immune checkpoint inhibitors (ICI) are being increasingly utilized both in clinical trials and in clinical practice. It is a form of biological therapy that targets tumors by activating the immune system, which in turn eliminates proliferating cancer cells. These have numerous immune-related adverse events (irAEs), one of which is myocarditis, which has high rates of mortality. This article was a narrative review of myocarditis related to ICI use. Studies from the PubMed, Cochrane, and American Society of Clinical Oncology (ASCO) databases were used in writing this review. The databases were searched for original publications for adverse effects related to ICI use and myocarditis specifically. There are numerous published instances of cancer immunotherapy causing myocarditis. ICI therapy has numerous benefits, as it upregulates the immune system to target cancer cells, utilizing the body's own defense mechanisms to target proliferating cells. Myocarditis is a serious side effect, however. Therefore, on balance, these monotherapies are worth using. While this literature review primarily identifies cross-reaction as the main mechanism of myocarditis, there are other possible mechanisms. One proposed mechanism involves a shared antigen between the myocardial tissue and the tumor. This mechanism is called molecular mimicry, where the monoclonal antibody attacks both the myocardial tissue and the tumor cell. Management of ICI-induced myocarditis has not been studied by randomized controlled trials or prospective studies, but based on previous case reports and case series it is mostly treated with steroids initially. An ICI rechallenge after temporary discontinuation appears conceivable in many cases, especially given its therapeutic effects, but only limited data are available on the safety of a rechallenge after an irAE. The lack of RCTs regarding rechallenge with an ICI after irAE, more so specifically about myocarditis, along with the overall results and the complexity involved in such cases once again emphasize the need to make decisions on an individual basis by a multidisciplinary expert working group. At the same time, the focus should also be on publishing more data as the need will grow along with the indications for ICI therapies.
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Affiliation(s)
- Rohail Gul
- Internal Medicine, Shifa Tameer-E-Millat University Shifa College of Medicine, Islamabad, PAK
| | | | - Anber Mahboob
- Internal Medicine, Sharif Medical and Dental College, Lahore, PAK
| | - Hira K Kareem
- Internal Medicine, King Edward Medical University, Lahore, PAK
| | - Arslan Inayat
- Internal Medicine, HSHS St. Marys Hospital, Decatur, USA
| | - Danish Safi
- Hematology and Medical Oncology, West Virginia University School of Medicine, Morgantown, USA
| | - Amir Kamran
- Hematology and Medical Oncology, Charleston Area Medical Center, Charleston, USA
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18
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Del Cid Fratti J, Paleru V, Bajaj M, Bhardwaj C. The toxic tango: TKI and TCI cardiotoxicities. Cardiooncology 2023; 9:44. [PMID: 38057847 DOI: 10.1186/s40959-022-00152-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 12/27/2022] [Indexed: 12/08/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) and Tyrosine kinase inhibitors (TKI) are effective for several types of cancers, but they can have several cardiotoxicity sides effects. We present a case of TKI-ICI toxicity resulting in multiorgan inflammatory syndrome with myocarditis and thrombotic STEMI that were successfully treated with high-dose steroids and PCI. CASE PRESENTATION Seventy-two year-old man patient treated with on pembrolizumab 200 mg IV every 3 weeks and Axitinib 5 mg PO q12h for the past 5 months complained of acute shortness of breath, altered mental status, and chronic diarrhea. Coronary angiography demonstrated a thrombotic lesion in the right coronary artery (RCA) that was treated successfully with percutaneous coronary intervention (PCI). Despite PCI he continued to complain of shortness of breath further workup with Cardiac MRI (CMR) was obtained showed an ejection fraction of 38%, small pericardial effusion, and delayed gadolinium enhancement (DGE) in the inferior wall suggestive of myocarditis. An empirical trial of high-dose steroids improved all patient symptoms and ejection fraction; therefore, the chemotherapy regimen was changed. CONCLUSION This case report highlights the potential vasculogenic effects of Axitinib and immune-related myocarditis of pembrolizumab. Cardiologists and oncologists should be vigilant for the cardiotoxic effects of Axitinib and pembrolizumab.
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Affiliation(s)
- Juan Del Cid Fratti
- Cardiology Department, OSF Healthcare/ University of Illinois at Peoria, Peoria, IL, USA.
| | - Vijaysree Paleru
- Cardiology Department, OSF Healthcare/ University of Illinois at Peoria, Peoria, IL, USA
| | - Madhuri Bajaj
- Oncology Department, OSF Healthcare/ University of Illinois at Peoria, Peoria, IL, USA
| | - Chetan Bhardwaj
- Cardiology Department, OSF Healthcare/ University of Illinois at Peoria, Peoria, IL, USA
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19
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Talukder S, Ghose A, Chakraborty T, Olsson-Brown A, Ramalingam S, Rosen SD, Young K, Lyon AR, Ghosh AK. Evolving cardiac biomarkers for immune checkpoint inhibitor related myocarditis in cancer patients. Int J Cardiol Heart Vasc 2023; 49:101278. [PMID: 37842144 PMCID: PMC10570005 DOI: 10.1016/j.ijcha.2023.101278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/26/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Suprateeka Talukder
- Norfolk and Norwich University Hospital, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Aruni Ghose
- Barts Cancer Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
- Cardio-Oncology Service, Barts Heart Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
- Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, London, UK
- Medical Oncology, Medway NHS Foundation Trust, Gillingham, Kent, UK
- Immuno-Oncology Clinical Network, UK
| | - Turja Chakraborty
- London Northwest University Healthcare NHS Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Anna Olsson-Brown
- Immuno-Oncology Clinical Network, UK
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Sivatharshini Ramalingam
- Cardio-Oncology Service, Royal Brompton Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Stuart D. Rosen
- Immuno-Oncology Clinical Network, UK
- London Northwest University Healthcare NHS Trust, London, UK
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - Kate Young
- The Royal Marsden Hospital, The Royal Marsden NHS Foundation Trust, London, UK
| | - Alexander R. Lyon
- Cardio-Oncology Service, Royal Brompton Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Arjun K. Ghosh
- Cardio-Oncology Service, Barts Heart Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
- Cardio-Oncology Service, University College London Hospitals NHS Foundation Trust, London, UK
- Hatter Cardiovascular Institute, UCL Institute of Cardiovascular Science, University College London, London, UK
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20
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Blum SM, Zlotoff DA, Smith NP, Kernin IJ, Ramesh S, Zubiri L, Caplin J, Samanta N, Martin SC, Tirard A, Sen P, Song Y, Barth J, Slowikowski K, Nasrallah M, Tantivit J, Manakongtreecheep K, Arnold BY, McGuire J, Pinto CJ, McLoughlin D, Jackson M, Chan P, Lawless A, Sharova T, Nieman LT, Gainor JF, Juric D, Mino-Kenudsen M, Sullivan RJ, Boland GM, Stone JR, Thomas MF, Neilan TG, Reynolds KL, Villani AC. Immune Responses in Checkpoint Myocarditis Across Heart, Blood, and Tumor. bioRxiv 2023:2023.09.15.557794. [PMID: 37790460 PMCID: PMC10542127 DOI: 10.1101/2023.09.15.557794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are widely used anti-cancer therapies that can cause morbid and potentially fatal immune-related adverse events (irAEs). ICI-related myocarditis (irMyocarditis) is uncommon but has the highest mortality of any irAE. The pathogenesis of irMyocarditis and its relationship to anti-tumor immunity remain poorly understood. We sought to define immune responses in heart, tumor, and blood during irMyocarditis and identify biomarkers of clinical severity by leveraging single-cell (sc)RNA-seq coupled with T cell receptor (TCR) sequencing, microscopy, and proteomics analysis of 28 irMyocarditis patients and 23 controls. Our analysis of 284,360 cells from heart and blood specimens identified cytotoxic T cells, inflammatory macrophages, conventional dendritic cells (cDCs), and fibroblasts enriched in irMyocarditis heart tissue. Additionally, potentially targetable, pro-inflammatory transcriptional programs were upregulated across multiple cell types. TCR clones enriched in heart and paired tumor tissue were largely non-overlapping, suggesting distinct T cell responses within these tissues. We also identify the presence of cardiac-expanded TCRs in a circulating, cycling CD8 T cell population as a novel peripheral biomarker of fatality. Collectively, these findings highlight critical biology driving irMyocarditis and putative biomarkers for therapeutic intervention.
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Affiliation(s)
- Steven M. Blum
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Daniel A. Zlotoff
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Neal P. Smith
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Isabela J. Kernin
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Swetha Ramesh
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Leyre Zubiri
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Joshua Caplin
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nandini Samanta
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Sidney C. Martin
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Alice Tirard
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Pritha Sen
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Transplant and Immunocompromised Host Program, Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital
| | - Yuhui Song
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
| | - Jaimie Barth
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Kamil Slowikowski
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mazen Nasrallah
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, North Shore Physicians Group, Department of Medicine, Mass General Brigham Healthcare Center, Lynn, MA, USA
| | - Jessica Tantivit
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Kasidet Manakongtreecheep
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Benjamin Y. Arnold
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - John McGuire
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Christopher J. Pinto
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Clinical Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel McLoughlin
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Clinical Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Monica Jackson
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Clinical Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - PuiYee Chan
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Clinical Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Aleigha Lawless
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Tatyana Sharova
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Linda T. Nieman
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
| | - Justin F. Gainor
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Dejan Juric
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mari Mino-Kenudsen
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Ryan J. Sullivan
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Genevieve M. Boland
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James R. Stone
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Molly F. Thomas
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tomas G. Neilan
- Harvard Medical School, Boston, MA, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry L. Reynolds
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alexandra-Chloé Villani
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Massachusetts General Hospital, Cancer Center, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
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21
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Paluri RK, Pulipati Y, Regalla DKR. Immune Checkpoint Inhibitors and Their Cardiovascular Adverse Effects. Oncol Rev 2023; 17:11456. [PMID: 38045806 PMCID: PMC10691592 DOI: 10.3389/or.2023.11456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 10/25/2023] [Indexed: 12/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have reshaped and have become a well-established treatment modality for multiple advanced-stage malignancies. ICIs block the immune system regulatory checkpoints, namely CTLA-4 and PD-1/PDL1, which provokes excess immune response against self-antigens. Immune modulation with ICIs can result in diverse immune-related adverse events targeting organ systems. Several cases of ICI-related cardiotoxicity were reported, while the actual incidence was likely underestimated due to heterogeneous clinical presentation. These include, but are not limited to, myocarditis, pericarditis, atherosclerosis, and arrhythmia. EKG, Troponin, Echocardiogram (TTE), and Cardiac MRI (CMRI) are indispensable diagnostic tools to aid in the management of cardiac adverse effects. Herein, we review the ICI-mediated cardiovascular adverse events, diagnosis, treatment strategies, and reintroduction of ICIs post-cardiotoxicity.
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Affiliation(s)
- Ravi Kumar Paluri
- Department of Hematology-Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States
| | - Yochitha Pulipati
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA, United States
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22
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Lessomo FYN, Mandizadza OO, Mukuka C, Wang ZQ. A comprehensive review on immune checkpoint inhibitors induced cardiotoxicity characteristics and associated factors. Eur J Med Res 2023; 28:495. [PMID: 37941006 PMCID: PMC10631013 DOI: 10.1186/s40001-023-01464-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023] Open
Abstract
Newly approved cancer drugs called ICIs have shown remarkable success in improving patient survival rates, but they also have the potential for inflammatory and immune-related side effects, including those affecting the cardiovascular system. Research has been conducted to understand the development of these toxicities and identify risk factors. This review focuses on the characteristics of ICI-induced cardiotoxicity and discusses the reported risk factors. It is important for cardio-oncologists to understand the basic concepts of these drugs to better understand how cardiotoxicities occur. It might be hard to find reports, where all patients treated with ICIs had developed cardiac toxicity, because there could be other existing and variable factors that influence the likelihood or risk of developing cardiotoxicity during treatment. Various clinical parameters have been explored as potential risk factors, and further investigation is needed through large-scale studies.
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Affiliation(s)
| | | | | | - Zhi-Quan Wang
- Cardiology Department, Zhongnan Hospital of Wuhan University, Wuhan, China.
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23
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Murtagh G, Januzzi JL, Scherrer‐Crosbie M, Neilan TG, Dent S, Ho JE, Appadurai V, McDermott R, Akhter N. Circulating Cardiovascular Biomarkers in Cancer Therapeutics-Related Cardiotoxicity: Review of Critical Challenges, Solutions, and Future Directions. J Am Heart Assoc 2023; 12:e029574. [PMID: 37889193 PMCID: PMC10727390 DOI: 10.1161/jaha.123.029574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 04/02/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
Cardiotoxicity is a growing concern in the oncology population. Transthoracic echocardiography and multigated acquisition scans have been used for surveillance but are relatively insensitive and resource intensive. Innovative imaging techniques are constrained by cost and availability. More sensitive, cost-effective cardiotoxicity surveillance strategies are needed. Circulating cardiovascular biomarkers could provide a sensitive, low-cost solution. Biomarkers such as troponins, natriuretic peptides (NPs), novel upstream signals of oxidative stress, inflammation, and fibrosis as well as panomic technologies have shown substantial promise, and guidelines recommend baseline measurement of troponins and NPs in all patients receiving potential cardiotoxins. Nonetheless, supporting evidence has been hampered by several limitations. Previous reviews have provided valuable perspectives on biomarkers in cancer populations, but important analytic aspects remain to be examined in depth. This review provides comprehensive assessment of critical challenges and solutions in this field, with focus on analytical issues relating to biomarker measurement and interpretation. Examination of evidence pertaining to common and serious forms of cardiotoxicity reveals that improved study designs incorporating larger, more diverse populations, registry-based approaches, and refinement of current definitions are key. Further efforts to harmonize biomarker methodologies including centralized biobanking and analyses, novel decision limits, and head-to-head comparisons are needed. Multimarker algorithms incorporating machine learning may allow rapid, personalized risk assessment. These improvements will not only augment the predictive value of circulating biomarkers in cardiotoxicity but may elucidate both direct and indirect relationships between cardiovascular disease and cancer, allowing biomarkers a greater role in the development and success of novel anticancer therapies.
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Affiliation(s)
| | - James L. Januzzi
- Division of Cardiology, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMAUSA
| | | | - Tomas G. Neilan
- Division of Cardiology, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMAUSA
| | - Susan Dent
- Duke Cancer Institute, Department of MedicineDuke UniversityDurhamNCUSA
| | - Jennifer E. Ho
- CardioVascular Institute and Division of Cardiology, Department of MedicineBeth Israel Deaconess Medicine CenterBostonMAUSA
| | - Vinesh Appadurai
- Division of Cardiovascular MedicineNorthwestern University Feinberg School of MedicineChicagoILUSA
- School of MedicineThe University of QueenslandSt LuciaQueenslandAustralia
| | - Ray McDermott
- Medical OncologySt. Vincent’s University HospitalDublinIreland
| | - Nausheen Akhter
- Division of Cardiovascular MedicineNorthwestern University Feinberg School of MedicineChicagoILUSA
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24
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Yu M, Tang W, Liang W, Xie B, Gao R, Ding P, Gu X, Wang M, Wen S, Sun P. PCSK9 inhibition ameliorates experimental autoimmune myocarditis by reducing Th17 cell differentiation through LDLR/STAT-3/ROR-γt pathway. Int Immunopharmacol 2023; 124:110962. [PMID: 37776771 DOI: 10.1016/j.intimp.2023.110962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/16/2023] [Accepted: 09/15/2023] [Indexed: 10/02/2023]
Abstract
Proprotein convertase subtilisin kexin type 9 (PCSK9) was characterized as a protein regulating circulating cholesterol metabolism; however, recent studies demonstrated a role for PCSK9 in inflammatory and autoimmune diseases unrelated to cholesterol alterations. The implication of PCSK9 in myocarditis is unclear and we aim at investigating the roles and mechanisms of PCSK9 in myocarditis. Male BALB/c mice received subcutaneous immunization with MyHC-α peptide on days 0 and 7 to establish the experimental autoimmune myocarditis (EAM) model. PCSK9 inhibitor, evolocumab, was administered subcutaneously once a week starting on day 0 and all mice were euthanized on day 21. Our results showed that PCSK9 inhibition ameliorated the cardiac inflammation of EAM mice. PCSK9 inhibition reduced both the levels of cardiac and peripheral blood PCSK9. We found that CD4+ T cells, CD8+ T cells, macrophages, and cardiomyocytes in the heart of EAM mice could express PCSK9. PCSK9 inhibition decreased the differentiation of cardiac Th17 cells by lowering ROR-γt levels but had no effects on Th1, Th2, and Treg cell differentiation. In vitro experiments of CD4+ T cells, we found that PCSK9 directly promoted Th17 cell differentiation through LDLR/STAT3/ROR-γt pathway. Collectively, we demonstrated that PCSK9 inhibition ameliorated the severity of EAM mice by reducing Th17 cell differentiation. PCSK9 is a promising target for treating myocarditis.
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Affiliation(s)
- Miao Yu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wenjing Tang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wei Liang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Baikang Xie
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ran Gao
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Peiwu Ding
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaoying Gu
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Min Wang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shuang Wen
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China.
| | - Peng Sun
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China.
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25
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Zatarain-Nicolás E, Martín P, Márquez Rodas I, Virizuela J, Martín García A, Mitroi C, Cosín Sales J, Barrios V, Sánchez-Cabo F, Ibañez B, de Castro Carpeño J, López Fernández T. Cardiovascular toxicity of checkpoint inhibitors: review of associated toxicity and design of the Spanish Immunotherapy Registry of Cardiovascular Toxicity. Clin Transl Oncol 2023; 25:3073-3085. [PMID: 37227656 DOI: 10.1007/s12094-023-03217-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/03/2022] [Accepted: 04/29/2023] [Indexed: 05/26/2023]
Abstract
Immune checkpoint inhibitors (ICI) have changed the prognosis of many tumors. However, concerning associated cardiotoxicity has been reported. Little is known about the real-life incidence-specific surveillance protocols or the translational correlation between the underlying mechanisms and the clinical presentation of ICI-induced cardiotoxicity. The lack of data from prospective studies led us to review the current knowledge and to present the creation of the Spanish Immunotherapy Registry of Cardiovascular Toxicity (SIR-CVT), a prospective registry of patients receiving ICI that aims to examine the role of hsa-miR-Chr8:96, (a specific serum biomarker of myocarditis) in the early diagnosis of ICI-induced myocarditis. An exhaustive prospective cardiac imaging study will be performed before and during the first 12 months of treatment. The correlation between clinical, imaging, and immunologic parameters may improve our understanding of ICI-induced cardiotoxicity and enable simpler surveillance protocols. We assess ICI-induced cardiovascular toxicity and describe the rationale of the SIR-CVT.
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Affiliation(s)
- Eduardo Zatarain-Nicolás
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBER-CV (Instituto de Salud Carlos III), Universidad Complutense, Madrid, Spain.
| | - Pilar Martín
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), CIBER-CV (Instituto de Salud Carlos III), Madrid, Spain
| | - Iván Márquez Rodas
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan Virizuela
- Medical Oncology Department, Hospital Universitario Virgen de la Macarena, Seville, Spain
| | - Ana Martín García
- Cardiology Department, Complejo Asistencial Universitario de Salamanca, IBSAL, USAL, CIBER-CV (Instituto de Salud Carlos III), Salamanca, Spain
| | - Cristina Mitroi
- Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBER-CV (Instituto de Salud Carlos III), Madrid, Spain
| | - Juan Cosín Sales
- Agencia de Investigación de la Sociedad Española de Cardiología (AISEC), Madrid, Spain
- Cardiology Department, Hospital Arnau de Vilanova, Universidad CEU-Cardenal Herrera, Valencia, Spain
| | - Vivencio Barrios
- Agencia de Investigación de la Sociedad Española de Cardiología (AISEC), Madrid, Spain
- Cardiology Department, Hospital Universitario Ramon y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Fátima Sánchez-Cabo
- Bioinformatics Unit, Centro Nacional de Investigaciones Cardiovasculares (CNIC), CIBER-CV (Instituto de Salud Carlos III), Madrid, Spain
| | - Borja Ibañez
- Cardiology Department, IIS-Fundación Jiménez Díaz University Hospital, CIBER-CV (Instituto de Salud Carlos III), CNIC, Madrid, Spain
| | | | - Teresa López Fernández
- Cardiology Service, Cardio-Oncology Unit, La Paz University Hospital and IdiPAz Research Institute, Madrid, Spain.
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Andreescu M. Recent Advances in Serum Biomarkers for Cardiological Risk Stratification and Insight into the Cardiac Management of the Patients With Hematological Malignancies Treated With Targeted Therapy. Cureus 2023; 15:e49696. [PMID: 38033434 PMCID: PMC10688222 DOI: 10.7759/cureus.49696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 12/02/2023] Open
Abstract
Cardiovascular diseases (CVD) have emerged as a common and serious complication of cancer treatment, particularly in patients undergoing cardiotoxic therapies. Over the last few years, the medical community has become increasingly aware of the potential for cardiotoxicity resulting from cancer treatments involving chemotherapy, targeted therapies, and radiation therapy. This recognition is due to the significant risk of morbidity and mortality in cancer patients and survivors resulting from such treatment-induced cardiovascular damage. While the cardiotoxic effects of chemotherapy and targeted therapy have been discussed in medical literature, only a limited number of studies have explored the role of serum biomarkers in cardiological risk stratification. In recent years, serum biomarkers have emerged as a valuable tool for assessing and managing cardiotoxicity in patients with hematological malignancies. This review article provides a summary of the current state of knowledge on the usefulness of biomarkers in managing cardiotoxicity resulting from different targeted therapies throughout the cancer care continuum. Although cardiac biomarkers have demonstrated potential in identifying subclinical cardiotoxicity and tracking the response to cardioprotective treatments, further research is necessary to determine optimal biomarkers and surveillance strategies. The incorporation of cardiac biomarkers into clinical practice in patients undergoing targeted therapies could potentially lead to improved long-term cardiovascular outcomes in cancer patients and survivors.
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Affiliation(s)
- Mihaela Andreescu
- Department of Hematology, Colentina Clinical Hospital, Bucharest, ROU
- Department of Clinical Sciences, Hematology, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest, ROU
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Addison D, Neilan TG, Barac A, Scherrer-Crosbie M, Okwuosa TM, Plana JC, Reding KW, Taqueti VR, Yang EH, Zaha VG. Cardiovascular Imaging in Contemporary Cardio-Oncology: A Scientific Statement From the American Heart Association. Circulation 2023; 148:1271-1286. [PMID: 37732422 DOI: 10.1161/cir.0000000000001174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Advances in cancer therapeutics have led to dramatic improvements in survival, now inclusive of nearly 20 million patients and rising. However, cardiovascular toxicities associated with specific cancer therapeutics adversely affect the outcomes of patients with cancer. Advances in cardiovascular imaging have solidified the critical role for robust methods for detecting, monitoring, and prognosticating cardiac risk among patients with cancer. However, decentralized evaluations have led to a lack of consensus on the optimal uses of imaging in contemporary cancer treatment (eg, immunotherapy, targeted, or biological therapy) settings. Similarly, available isolated preclinical and clinical studies have provided incomplete insights into the effectiveness of multiple modalities for cardiovascular imaging in cancer care. The aims of this scientific statement are to define the current state of evidence for cardiovascular imaging in the cancer treatment and survivorship settings and to propose novel methodological approaches to inform the optimal application of cardiovascular imaging in future clinical trials and registries. We also propose an evidence-based integrated approach to the use of cardiovascular imaging in routine clinical settings. This scientific statement summarizes and clarifies available evidence while providing guidance on the optimal uses of multimodality cardiovascular imaging in the era of emerging anticancer therapies.
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Liu X, Zeng Z, Cao J, Li X, Muhetaer M, Jin Z, Cai H, Lu Z. Sintilimab-Induced Myocarditis in a Patient with Gastric Cancer: A Case Report and Literature Review. J Cardiovasc Dev Dis 2023; 10:422. [PMID: 37887869 PMCID: PMC10607029 DOI: 10.3390/jcdd10100422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/15/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as a powerful and efficacious therapeutic approach for many cancer patients. Sintilimab is a fully human IgG4 monoclonal antibody that binds with programmed cell death receptor-1 (PD-1) to block its interaction with ligands, thereby enhancing the antitumor effects of T cells. However, ICIs may induce immune-related adverse events (irAEs) in various systems and organs, with fulminant myocarditis being the most severe one. We report the case of a 45-year-old female with gastric cancer who developed chest pain two weeks after chemotherapy with sintilimab; she was diagnosed with immune-associated fulminant myocarditis and experienced an Adams-Stokes syndrome attack in the hospital. Eventually, she was discharged after being treated with methylprednisolone, immunoglobulin, and an IABP.
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Affiliation(s)
- Xin Liu
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Ziyue Zeng
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Jianlei Cao
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Xianqing Li
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Muheremu Muhetaer
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Zhili Jin
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Huanhuan Cai
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
| | - Zhibing Lu
- Department of Cardiology, Zhongnan Hospital, Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China; (X.L.); (Z.Z.); (J.C.); (X.L.); (M.M.); (Z.J.)
- Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430071, China
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Wang C, Zhao G, Zhang Z, Yang L, Liu S, Li G, Wang H, Huang J, Wang S, Li N. Immune checkpoint inhibitor-associated myocarditis: a systematic analysis of case reports. Front Immunol 2023; 14:1275254. [PMID: 37876928 PMCID: PMC10590906 DOI: 10.3389/fimmu.2023.1275254] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/22/2023] [Indexed: 10/26/2023] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) therapy can be complicated by their potential cardiovascular toxicities, including myocarditis. Nowadays, no prospective trials have focused on ICI-associated myocarditis optimized management. Available evidence only come from case reports or series. A systematic case reports analysis was conducted to collect and evaluate emerging evidence of ICI-associated myocarditis to provide more information to clinicians. Methods We performed a literature search for eligible case reports or series published between January 2018 and May 2023 using the PubMed database. Then, we extracted interesting information via table form. Finally, this study included 113 publications on 106 patients with ICI-associated myocarditis. Results Myocarditis was found to be a highly life-threatening disease, with 53.8% of cases. Over half of cases were life-threatening (G4, 23.6%) or severe (G3, 35.8%) and required glucocorticoids. Higher rates of improvement were associated with the best response to ICI for complete response/partial response (72.7% vs. 53.9%), glucocorticoid administration (30% vs. 22%), and discontinuation of ICI (58.8% vs. 32.1%). Consequently, ICI-associated G3-G4 myocarditis should be treated with a combination of discontinuation of ICIs, high-dose glucocorticoids, other drugs, chemical drugs, plasma exchange, and life support. For moderate G1 or G2 cases, discontinuation of ICIs and regular-dose glucocorticoids should be considered. Conclusion Once full recovery or improvement was achieved; glucocorticoids can be administered at low doses or stopped. Notably, re-challenge with ICIs appears feasible after resolution or meaningful improvement of myocarditis.
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Affiliation(s)
- Caie Wang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Guo Zhao
- Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhen Zhang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Lukui Yang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Shihao Liu
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Guifang Li
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Hongxia Wang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Jiaxin Huang
- Department of Pharmacy, the First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Shuhang Wang
- Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kerneis M, Cohen F, Combes A, Amoura Z, Pare C, Brugier D, Puymirat E, Abtan J, Lattuca B, Dillinger JG, Hauguel-Moreau M, Silvain J, Salem JE, Gandjbakhch E, Hekimian G, Redheuil A, Vicaut E, Montalescot G. Rationale and design of the ARAMIS trial: Anakinra versus placebo, a double blind randomized controlled trial for the treatment of acute myocarditis. Arch Cardiovasc Dis 2023; 116:460-466. [PMID: 37640625 DOI: 10.1016/j.acvd.2023.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Acute myocarditis is an inflammation of the myocardium that can cause life-threatening events. However, anti-inflammatory strategies did not reduce the risk of clinical outcomes in randomized trials. Recently, experimental studies have suggested that specific blockade of the interleukin-1β immune innate pathway could be effective in acute myocarditis. AIM To test the hypothesis that inhibition of the interleukin-1β immune innate pathway can reduce the risk of clinical events in acute myocarditis. METHODS The "Anakinra versus placebo double blind Randomized controlled trial for the treatment of Acute MyocarditIS" (ARAMIS) trial (ClinicalTrials.gov identifier: NCT03018834) is a national multicentre randomized parallel-group double blind study among symptomatic patients with elevated cardiac troponin and cardiac magnetic resonance-proven acute myocarditis. Patients (n=120) are randomized within 72hours of hospital admission to receive a daily subcutaneous dose of anakinra 100mg or placebo during the hospitalization, in addition to standard of care, including an angiotensin-converting enzyme inhibitor and a beta-blocker. The primary endpoint is the number of days alive free from any myocarditis complication, including ventricular arrhythmias, heart failure, recurrent chest pain requiring medication and ventricular dysfunction (defined as left ventricular ejection fraction<50%), from randomization to 28 days after hospital discharge. At 28 days after discharge, patients with normal left ventricular ejection fraction are then randomized to angiotensin-converting enzyme inhibitor continuation or discontinuation and all patients are followed for 1 year, with regular left ventricular function evaluation. CONCLUSIONS ARAMIS is the first trial evaluating inhibition of the interleukin-1β immune innate pathway in the setting of acute myocarditis. Although of small size, it will be the largest randomized trial in acute myocarditis, a serious and poorly studied cardiac condition.
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Affiliation(s)
- Mathieu Kerneis
- Institut de cardiologie, hôpital Pitié-Salpêtrière, Inserm UMRS 1166-ICAN (Institute of CardioMetabolism and Nutrition), AP-HP, Sorbonne université, ACTION Study Group, 75013 Paris, France.
| | - Fleur Cohen
- Internal Medicine Department, French National Centre for Rare Systemic Diseases, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne université, 75013 Paris, France
| | - Alain Combes
- Institut de cardiologie, hôpital Pitié-Salpêtrière, Inserm UMRS 1166-ICAN (Institute of CardioMetabolism and Nutrition), AP-HP, Sorbonne université, ACTION Study Group, 75013 Paris, France; Service de médecine intensive-réanimation, institut de cardiologie, hôpital Pitié-Salpêtrière, Sorbonne université, 75013 Paris, France
| | - Zahir Amoura
- Internal Medicine Department, French National Centre for Rare Systemic Diseases, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne université, 75013 Paris, France
| | - Carine Pare
- Unité de recherche clinique, hôpital Lariboisière, AP-HP, Université Paris-Diderot/Paris 7, ACTION Study Group, 75010 Paris, France
| | - Delphine Brugier
- Institut de cardiologie, hôpital Pitié-Salpêtrière, Inserm UMRS 1166-ICAN (Institute of CardioMetabolism and Nutrition), AP-HP, Sorbonne université, ACTION Study Group, 75013 Paris, France
| | - Etienne Puymirat
- Department of Cardiology, hôpital européen Georges-Pompidou, AP-HP, université Paris-Descartes, 75015 Paris, France
| | - Jeremie Abtan
- DHU (département hospitalo-universitaire) FIRE (Fibrosis, Inflammation, REmodelling), hôpital Bichat, AP-HP, université Paris-Diderot, Sorbonne-Paris-Cité, Inserm U-1148, 75018 Paris, France
| | - Benoit Lattuca
- Université de Montpellier, ACTION Study Group, 30029 Nîmes, France
| | - Jean-Guillaume Dillinger
- Service de cardiologie, centre hospitalier universitaire de Nîmes, hôpital Lariboisière/Saint-Louis, AP-HP, Inserm U942, université de Paris, 75010 Paris, France
| | - Marie Hauguel-Moreau
- Department of Cardiology, Ambroise-Paré Hospital, AP-HP, université de Versailles-Saint-Quentin, ACTION Study Group, 92100 Boulogne-Billancourt, France
| | - Johanne Silvain
- Institut de cardiologie, hôpital Pitié-Salpêtrière, Inserm UMRS 1166-ICAN (Institute of CardioMetabolism and Nutrition), AP-HP, Sorbonne université, ACTION Study Group, 75013 Paris, France
| | - Joe-Elie Salem
- Clinical Investigations Centre Paris-Est, hôpital Pitié-Salpêtrière, AP-HP, Inserm, Sorbonne université, 75013 Paris, France
| | - Estelle Gandjbakhch
- Institut de cardiologie, hôpital Pitié-Salpêtrière, Inserm UMRS 1166-ICAN (Institute of CardioMetabolism and Nutrition), AP-HP, Sorbonne université, ACTION Study Group, 75013 Paris, France
| | - Guillaume Hekimian
- Institut de cardiologie, hôpital Pitié-Salpêtrière, Inserm UMRS 1166-ICAN (Institute of CardioMetabolism and Nutrition), AP-HP, Sorbonne université, ACTION Study Group, 75013 Paris, France; Service de médecine intensive-réanimation, institut de cardiologie, hôpital Pitié-Salpêtrière, Sorbonne université, 75013 Paris, France
| | - Alban Redheuil
- Institut de cardiologie, hôpital Pitié-Salpêtrière, Inserm UMRS 1166-ICAN (Institute of CardioMetabolism and Nutrition), AP-HP, Sorbonne université, ACTION Study Group, 75013 Paris, France; Department of Cardiovascular Imaging, Interventional and Thoracic Radiology (DICVRIT), hôpital Pitié-Salpêtrière, AP-HP, laboratoire d'imagerie biomédicale, Sorbonne universités, université Paris 06 (UPMC), 75013 Paris, France; Inserm, CNRS 7371, 75006 Paris, France
| | - Eric Vicaut
- Unité de recherche clinique, hôpital Lariboisière, AP-HP, Université Paris-Diderot/Paris 7, ACTION Study Group, 75010 Paris, France
| | - Gilles Montalescot
- Institut de cardiologie, hôpital Pitié-Salpêtrière, Inserm UMRS 1166-ICAN (Institute of CardioMetabolism and Nutrition), AP-HP, Sorbonne université, ACTION Study Group, 75013 Paris, France
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Cautela J, Deharo F, Thuny F. Overcoming challenges of immune checkpoint inhibitor-induced myocarditis diagnosis. Arch Cardiovasc Dis 2023; 116:429-432. [PMID: 37596110 DOI: 10.1016/j.acvd.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/20/2023]
Affiliation(s)
- Jennifer Cautela
- Department of Cardiology, North Hospital, Assistance publique-Hôpitaux de Marseille, Centre for CardioVascular and Nutrition Research (C2VN), Unit of Heart Failure and Valvular Heart Diseases, Aix-Marseille University, University Mediterranean Center of Cardio-Oncology,, Inserm 1263, Inrae 1260, Marseille, France.
| | - Francois Deharo
- Department of Cardiology, North Hospital, Assistance publique-Hôpitaux de Marseille, Centre for CardioVascular and Nutrition Research (C2VN), Unit of Heart Failure and Valvular Heart Diseases, Aix-Marseille University, University Mediterranean Center of Cardio-Oncology,, Inserm 1263, Inrae 1260, Marseille, France
| | - Franck Thuny
- Department of Cardiology, North Hospital, Assistance publique-Hôpitaux de Marseille, Centre for CardioVascular and Nutrition Research (C2VN), Unit of Heart Failure and Valvular Heart Diseases, Aix-Marseille University, University Mediterranean Center of Cardio-Oncology,, Inserm 1263, Inrae 1260, Marseille, France
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He Y, Chen W, Cai J, Luo C, Zhou C, Wei L. PD-1 inhibitors-associated myocarditis in non-small cell lung cancer patients. J Thorac Dis 2023; 15:4606-4619. [PMID: 37868865 PMCID: PMC10586979 DOI: 10.21037/jtd-23-596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 07/21/2023] [Indexed: 10/24/2023]
Abstract
Background Immune checkpoint inhibitors (ICIs)-associated myocarditis remains a rare but fatal adverse event. The authors sought to provide a comprehensive clinical description of ICI-associated myocarditis by analyzing symptoms, laboratory indicators, imaging features, and management of ICI-associated myocarditis in patients with non-small cell lung cancer (NSCLC). Methods A retrospective study was conducted to analyze 14 ICI-associated myocarditis cases and 45 control patients to clarify clinical features of ICI-associated myocarditis. Detailed laboratory tests and imaging examinations were performed in 14 cases, and the rescue process and follow-up after the onset of myocarditis were recorded. Results A total of 14 (2.08%) NSCLC patients developed ICI-related myocarditis, with a median time of onset of 34 days (interquartile range, 12 to 146 days) after ICI initiation. The most common concurrent adverse events in cases were myositis (P<0.001) and peripheral neuritis (P<0.001). Among cases, cardiac troponin I (cTnI) levels were abnormally elevated in 92% of patients, and electrocardiogram (ECG) showed abnormal in all cases. Steroid therapy was used in 92.9% of patients with ICI-associated myocarditis, of which the response rate to steroids was 76.9% and the mortality rate was 7.1%. A dose of 1 g/d of glucocorticoid supplemented by immunoglobulin was observed to be effective for severe myocarditis. Conclusions Early identification and treatment are essential for managing myocarditis caused by ICI. Routine monitoring of cTnI level and ECG is most sensitive for the early diagnosis of ICI-related myocarditis. High-dose of glucocorticoids can effectively relieve the symptoms of ICI-associated myocarditis and stabilize the condition, especially for fulminant myocarditis.
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Affiliation(s)
- Yuwen He
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wanwen Chen
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Junying Cai
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Caiyin Luo
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chengzhi Zhou
- State Key Laboratory of Respiratory Disease, National Clinical Research Centre for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li Wei
- Department of Pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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O'Shea MP, Karikalan SA, Yusuf A, Barry T, Habib E, O'Shea J, Killian M, Baqal E, Nayak S, Masson R, Hermann J, Shah S, Ayoub C, Masry HE. Complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis. Cardiooncology 2023; 9:34. [PMID: 37730763 PMCID: PMC10510176 DOI: 10.1186/s40959-023-00185-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/29/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI) myocarditis is associated with significant mortality risk. Electrocardiogram (ECG) changes in ICI myocarditis have strong prognostic value. However the impact of complete heart block (CHB) is not well defined. This study sought to evaluate the impact of CHB on mortality in ICI myocarditis, and to identify clinical predictors of mortality and CHB incidence. METHODS We conducted a retrospective cohort study of patients with ICI myocarditis at three Mayo Clinic sites from 1st January 2010 to 31st September 2022 to evaluate mortality rates at 180 days. Clinical, laboratory, ECG, echocardiographic, and cardiac magnetic resonance imaging (CMR) characteristics were assessed. Cox and logistic regression were performed for associations with mortality and CHB respectively. RESULTS Of 34 identified cases of ICI myocarditis, 7 (20.6%) had CHB. CHB was associated with higher mortality (HR 7.41, p = 0.03, attributable fraction 86.5%). Among those with CHB, troponin T (TnT) < 1000 ng/dL, low white blood cell count and high ventricular rate at admission were protective. There was trend towards increased survival among patients who underwent permanent pacemaker insertion (p = 0.051), although most experienced device lead complications. Factors associated with development of CHB included prolonged PR and QRS intervals and low Sokolow Lyon Index. Where these were normal and TnT was < 1000 ng/dL, no deaths occurred. Impaired myocardial longitudinal strain was sensitive for ICI myocarditis but was not prognostically significant. CONCLUSION There is a strong temporal association between CHB and early mortality in people with ICI myocarditis. Focusing on arrhythmogenic complications can be helpful in predicting outcomes for this group of critically ill individuals.
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Affiliation(s)
- Michael P O'Shea
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | | | - Ali Yusuf
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Eiad Habib
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | | | - Michael Killian
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Eman Baqal
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Srishti Nayak
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Rajeev Masson
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | | | - Shimoli Shah
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Hicham El Masry
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA
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Iengo M, Topa E, Cuomo A, Marone G, Poto R, Varricchi G, Cristinziano L, Galdiero MR, Ferrara AL, Loffredo S, Formisano L, Troiani T, Mercurio V, Tocchetti CG. The broad spectrum of cardiotoxicities from immunotherapies. Front Cardiovasc Med 2023; 10:1259620. [PMID: 37781307 PMCID: PMC10540439 DOI: 10.3389/fcvm.2023.1259620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Affiliation(s)
- Martina Iengo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Ester Topa
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Giancarlo Marone
- Department of Pharmacy, Moscati Hospital Pharmacy, Aversa, Italy
| | - Remo Poto
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | | | - Maria Rosaria Galdiero
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
| | - Anne Lise Ferrara
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Luigi Formisano
- Department of Medicine and Surgery, Federico II University, Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
| | - Teresa Troiani
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
- Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
- Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
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Cuenca JA, Hanmandlu A, Wegner R, Botdorf J, Tummala S, Iliescu CA, Nates JL, Reddy DR. Management of respiratory failure in immune checkpoint inhibitors-induced overlap syndrome: a case series and review of the literature. BMC Anesthesiol 2023; 23:310. [PMID: 37700240 PMCID: PMC10496364 DOI: 10.1186/s12871-023-02257-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 08/24/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Checkpoint inhibitor-induced overlap syndrome ([OS] myocarditis, and myositis with or without myasthenia gravis) is rare but life-threatening. CASES PRESENTATION Here we present a case series of four cancer patients that developed OS. High troponinemia raised the concern for myocarditis in all the cases. However, the predominant clinical feature differed among the cases. Two patients showed marked myocarditis with a shorter hospital stay. The other two patients had a prolonged ICU stay due to severe neuromuscular involvement secondary to myositis and myasthenia gravis. Treatment was based on steroids, plasmapheresis, intravenous immunoglobulin, and immunosuppressive biological agents. CONCLUSION The management of respiratory failure is challenging, particularly in those patients with predominant MG. Along with intensive clinical monitoring, bedside respiratory mechanics can guide the decision-making process of selecting a respiratory support method, the timing of elective intubation and extubation.
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Affiliation(s)
- John A Cuenca
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Ankit Hanmandlu
- McGovern School of Medicine, University of Texas, Houston, TX, USA
| | - Robert Wegner
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Joshua Botdorf
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Sudhakar Tummala
- Department of Neuro-oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cezar A Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph L Nates
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Dereddi R Reddy
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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36
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Vasbinder A, Ismail A, Salem JE, Hayek SS. Role of Biomarkers in the Management of Immune-Checkpoint Inhibitor-Related Myocarditis. Curr Cardiol Rep 2023; 25:959-967. [PMID: 37436648 DOI: 10.1007/s11886-023-01915-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/29/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI)-related myocarditis poses a major clinical challenge given its non-specific presentation, rapid progression, and high mortality rate. Here, we review the role of blood-based biomarkers in the clinical management of patients with ICI-related myocarditis. RECENT FINDINGS Myocardial injury, its unique pattern, and the co-occurrence with myositis are defining features of ICI-related myocarditis. Non-cardiac biomarkers, specifically creatinine phosphokinase, precedes the symptomatic presentation and is highly sensitive for diagnosing ICI-related myocarditis, making them useful screening biomarkers. Combined elevations in cardiac troponins and non-cardiac biomarkers improve the confidence of an ICI myocarditis diagnosis. High troponin and creatinine phosphokinase levels are strongly associated with severe outcomes. We propose biomarker-based algorithms for the monitoring and diagnosis of ICI-related myocarditis. Biomarkers, such as cardiac troponins and creatine phosphokinase, can be used in combination in the monitoring, diagnosis, and prognostication of patients with ICI-related myocarditis.
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Affiliation(s)
- Alexi Vasbinder
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA
| | - Anis Ismail
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA
| | - Joe-Elie Salem
- Department of Pharmacology and Clinical Investigation Centre, Pitié-Salpetriere Hospital, Sorbonne Universite, Paris, France
| | - Salim S Hayek
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA.
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37
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van Heeswijk RB, Bauer WR, Bönner F, Janjic JM, Mulder WJM, Schreiber LM, Schwitter J, Flögel U. Cardiovascular Molecular Imaging With Fluorine-19 MRI: The Road to the Clinic. Circ Cardiovasc Imaging 2023; 16:e014742. [PMID: 37725674 DOI: 10.1161/circimaging.123.014742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Fluorine-19 (19F) magnetic resonance imaging is a unique quantitative molecular imaging modality that makes use of an injectable fluorine-containing tracer that generates the only visible 19F signal in the body. This hot spot imaging technique has recently been used to characterize a wide array of cardiovascular diseases and seen a broad range of technical improvements. Concurrently, its potential to be translated to the clinical setting is being explored. This review provides an overview of this emerging field and demonstrates its diagnostic potential, which shows promise for clinical translation. We will describe 19F magnetic resonance imaging hardware, pulse sequences, and tracers, followed by an overview of cardiovascular applications. Finally, the challenges on the road to clinical translation are discussed.
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Affiliation(s)
- Ruud B van Heeswijk
- Department of Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Switzerland (R.B.v.H.)
| | - Wolfgang R Bauer
- Department of Internal Medicine I, Universitätsklinikum Würzburg, Germany (W.R.B.)
| | - Florian Bönner
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of Heinrich Heine University, University Hospital Düsseldorf, Germany (F.B.)
| | - Jelena M Janjic
- Graduate School of Pharmaceutical Sciences, School of Pharmacy, Duquesne University, Pittsburgh, PA (J.M.J.)
| | - Willem J M Mulder
- Laboratory of Chemical Biology, Department of Biochemical Engineering, Eindhoven University of Technology, the Netherlands (W.J.M.M.)
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands (W.J.M.M.)
| | - Laura M Schreiber
- Chair of Molecular and Cellular Imaging, Comprehensive Heart Failure Center (CHFC), Wuerzburg University Hospitals, Germany (L.M.S.)
| | - Juerg Schwitter
- Division of Cardiology, Cardiovascular Department (J.S.), Lausanne University Hospital (CHUV), Switzerland
- CMR Center (J.S.), Lausanne University Hospital (CHUV), Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Switzerland (J.S.)
| | - Ulrich Flögel
- Experimental Cardiovascular Imaging (U.F.), Heinrich Heine University, Germany
- Cardiovascular Research Institute Düsseldorf (CARID) (U.F.), Heinrich Heine University, Germany
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Raschi E, Rossi S, De Giglio A, Fusaroli M, Burgazzi F, Rinaldi R, Potena L. Cardiovascular Toxicity of Immune Checkpoint Inhibitors: A Guide for Clinicians. Drug Saf 2023; 46:819-833. [PMID: 37341925 PMCID: PMC10442274 DOI: 10.1007/s40264-023-01320-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/22/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment and care of patients with cancer owing to unique features, including the occurrence of the so-called immune-related adverse events (irAEs). A multidisciplinary team, possibly including a cardio-oncology specialist, is warranted to achieve a favorable patient outcome. Cardiovascular toxicity, especially myocarditis, emerged as a life-threatening irAE in the real-word setting, and the European Society of Cardiology has recently published the first guideline on cardio-oncology to increase awareness and promote a standardized approach to tackle this complex multimodal issue, including diagnostic challenges, assessment, treatment, and surveillance of patients with cancer receiving ICIs. In this article, through a question & answer format made up of case vignettes, we offer a clinically oriented overview on the latest advancements of ICI-related cardiovascular toxicity, focusing on myocarditis and associated irAEs (myositis and myasthenia gravis within the so-called overlap syndrome), with the purpose of assisting clinicians and healthcare professionals in daily clinical practice.
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Affiliation(s)
- Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy.
| | - Simone Rossi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Andrea De Giglio
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Michele Fusaroli
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Flavio Burgazzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luciano Potena
- Unit of Heart Failure and Transplantation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Chitsazan M, Amin A, Ladel L, Baig A, Chitsazan M. Cardiovascular Toxicity Associated With Immune Checkpoint Inhibitor Therapy: A Comprehensive Review. Crit Pathw Cardiol 2023; 22:69-82. [PMID: 37363862 DOI: 10.1097/hpc.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Immune checkpoint inhibitors (ICIs), a significant breakthrough treatment of cancer, exert their function through enhancing the immune system's ability to recognize and attack cancer cells. However, these revolutionary cancer treatments have been associated with a range of immune-related adverse effects, including cardiovascular toxicity. The most commonly reported cardiovascular toxicities associated with ICIs are myocarditis, pericarditis, arrhythmias, and vasculitis. These cardiovascular manifestations are often severe and can lead to life-threatening complications. Therefore, prompt identification and management of these toxicities is critical, and a multidisciplinary teamwork by cardiologists and oncologists are required to ensure optimal patient outcomes. In this review, we summarize the current knowledge on the mechanisms underlying ICI-associated cardiovascular toxicity, clinical presentations of these toxicities, potential risk factors, diagnosis, management, and surveillance strategies during ICI therapy. While ICIs have already transformed cancer treatment, further research is needed to better understand and manage their immune-related cardiovascular effects, and possibly, to identify biomarkers which can predict the occurrence of these cardiovascular complications.
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Affiliation(s)
| | - Ahmad Amin
- Medstar Union Memorial Hospital, Baltimore, MD
| | - Luisa Ladel
- From the Department of Medicine, Norwalk Hospital, Norwalk, CT
| | - Alyza Baig
- From the Department of Medicine, Norwalk Hospital, Norwalk, CT
| | - Mitra Chitsazan
- Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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40
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He W, Zhou L, Xu K, Li H, Wang JJ, Chen C, Wang D. Immunopathogenesis and immunomodulatory therapy for myocarditis. Sci China Life Sci 2023; 66:2112-2137. [PMID: 37002488 PMCID: PMC10066028 DOI: 10.1007/s11427-022-2273-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/16/2023] [Indexed: 04/03/2023]
Abstract
Myocarditis is an inflammatory cardiac disease characterized by the destruction of myocardial cells, infiltration of interstitial inflammatory cells, and fibrosis, and is becoming a major public health concern. The aetiology of myocarditis continues to broaden as new pathogens and drugs emerge. The relationship between immune checkpoint inhibitors, severe acute respiratory syndrome coronavirus 2, vaccines against coronavirus disease-2019, and myocarditis has attracted increased attention. Immunopathological processes play an important role in the different phases of myocarditis, affecting disease occurrence, development, and prognosis. Excessive immune activation can induce severe myocardial injury and lead to fulminant myocarditis, whereas chronic inflammation can lead to cardiac remodelling and inflammatory dilated cardiomyopathy. The use of immunosuppressive treatments, particularly cytotoxic agents, for myocarditis, remains controversial. While reasonable and effective immunomodulatory therapy is the general trend. This review focuses on the current understanding of the aetiology and immunopathogenesis of myocarditis and offers new perspectives on immunomodulatory therapies.
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Affiliation(s)
- Wu He
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Ling Zhou
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Ke Xu
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Huihui Li
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - James Jiqi Wang
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China.
| | - DaoWen Wang
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China.
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41
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Gong J, Neilan TG, Zlotoff DA. Mediators and mechanisms of immune checkpoint inhibitor-associated myocarditis: Insights from mouse and human. Immunol Rev 2023; 318:70-80. [PMID: 37449556 PMCID: PMC10528547 DOI: 10.1111/imr.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/20/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
The broad application of immune checkpoint inhibitors (ICIs) has led to significant gains in cancer outcomes. By abrogating inhibitory signals, ICIs promote T cell targeting of cancer cells but can frequently trigger autoimmune manifestations, termed immune-related adverse events (irAEs), affecting essentially any organ system. Among cardiovascular irAEs, immune-related myocarditis (irMyocarditis) is the most described and carries the highest morbidity. The currently recommended treatment for irMyocarditis is potent immunosuppression with corticosteroids and other agents, but this has limited evidence basis. The cellular pathophysiology of irMyocarditis remains poorly understood, though mouse models and human data have both implicated effector CD8+ T cells, some of which are specific for the cardiomyocyte protein α-myosin. While the driving molecular signals and transcriptional programs are not well defined, the involvement of chemokine receptors such as CCR5 and CXCR3 has been proposed. Fundamental questions regarding why only approximately 1% of ICI recipients develop irMyocarditis and why irMyocarditis carries a much worse prognosis than other forms of lymphocytic myocarditis remain unanswered. Further work in both murine systems and with human samples are needed to identify better tools for diagnosis, risk-stratification, and treatment.
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Affiliation(s)
- Jingyi Gong
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Daniel A. Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA
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42
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Marquet Y, Hékimian G, Lebreton G, Kerneis M, Rouvier P, Bay P, Mathian A, Bréchot N, Chommeloux J, Petit M, Gautier M, Lefevre L, Saura O, Levy D, Quentric P, Moyon Q, Ortuno S, Schmidt M, Leprince P, Luyt CE, Combes A, Pineton de Chambrun M. Diagnostic yield, safety and therapeutic consequences of myocardial biopsy in clinically suspected fulminant myocarditis unweanable from mechanical circulatory support. Ann Intensive Care 2023; 13:78. [PMID: 37653258 PMCID: PMC10471530 DOI: 10.1186/s13613-023-01169-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 08/03/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Fulminant myocarditis is a rare and severe disease whose definite and etiological diagnoses rely on pathological examination. Albeit, myocardial biopsy can be associated with significant morbidity and mortality, its therapeutic consequences are unclear. We conducted a study to determine the diagnostic yield, the safety and the therapeutic consequences of myocardial biopsy in patients with fulminant clinically suspected myocarditis unweanable from mechanical circulatory support (MCS). METHODS Monocenter, retrospective, observational cohort study in a 26-bed French tertiary ICU between January 2002 and February 2019. Inclusion of all fulminant clinically suspected myocarditis patients undergoing in-ICU myocardial biopsy while being on MCS. The primary endpoint was the proportion of patients classified as definite myocarditis using Bonaca criteria before and after including myocardial biopsy results. RESULTS Forty-seven patients (median age 41 [30-47], female 53%) were included: 55% died before hospital discharge, 34% could be bridged-to-recovery and 15% bridged-to-transplant. Myocardial biopsy was endomyocardial or surgical in 36% and 64% cases respectively. Tamponade requiring emergency pericardiocentesis occurred in 29% patients after endomyocardial biopsy. After adding the biopsy results in the Bonaca classification algorithm the percentage of definite myocarditis raised from 13 to 55% (p < 0.0001). The rate of biopsy-related treatments modifications was 13%, leading to patients' recovery in only 4% patients. CONCLUSIONS In clinically suspected myocarditis unweanable from MCS, myocardial biopsy increased the rate of definite myocarditis but was associated with a low rate of treatment modification and a significant proportion of adverse events. We believe the benefit/risk ratio of myocardial biopsy should be more carefully weighted in these frail and selected patients than suggested by actual guidelines. Further prospective studies are now needed to determine its value in patients under MCS.
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Affiliation(s)
- Yann Marquet
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Guillaume Hékimian
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Guillaume Lebreton
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- Service de Chirurgie Cardio-Thoracique, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Paris, France
| | - Mathieu Kerneis
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- ACTION Study Group, Département de Cardiologie, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Philippe Rouvier
- Service d'Anatomopathologie, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Pierre Bay
- AP-HP, Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation and UPEC (Université Paris Est), INSERM, Unité U955, Équipe 18, 94010, Créteil, France
| | - Alexis Mathian
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut E3M, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Juliette Chommeloux
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Matthieu Petit
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Melchior Gautier
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Lucie Lefevre
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Ouriel Saura
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - David Levy
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Paul Quentric
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut E3M, Paris, France
- Sorbonne Université, Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Quentin Moyon
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut E3M, Paris, France
| | - Sofia Ortuno
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Pascal Leprince
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- Service de Chirurgie Cardio-Thoracique, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Paris, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex, France.
- Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France.
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut E3M, Paris, France.
- Sorbonne Université, Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France.
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Mikail N, Chequer R, Imperiale A, Meisel A, Bengs S, Portmann A, Gimelli A, Buechel RR, Gebhard C, Rossi A. Tales from the future-nuclear cardio-oncology, from prediction to diagnosis and monitoring. Eur Heart J Cardiovasc Imaging 2023; 24:1129-1145. [PMID: 37467476 PMCID: PMC10501471 DOI: 10.1093/ehjci/jead168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023] Open
Abstract
Cancer and cardiovascular diseases (CVD) often share common risk factors, and patients with CVD who develop cancer are at high risk of experiencing major adverse cardiovascular events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced non-invasive cardiac imaging has raised great interest in the early detection of CVD and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer-treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments and discuss the specific role of nuclear cardiology alongside other non-invasive imaging techniques.
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Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Renata Chequer
- Department of Nuclear Medicine, Bichat University Hospital, AP-HP, University Diderot, 75018 Paris, France
| | - Alessio Imperiale
- Nuclear Medicine, Institut de Cancérologie de Strasbourg Europe (ICANS), University Hospitals of Strasbourg, 67093 Strasbourg, France
- Molecular Imaging-DRHIM, IPHC, UMR 7178, CNRS/Unistra, 67093 Strasbourg, France
| | - Alexander Meisel
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Kantonsspital Glarus, Burgstrasse 99, 8750 Glarus, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
| | - Alessia Gimelli
- Imaging Department, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124 Pisa, Italy
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
- Department of Cardiology, University Hospital Inselspital Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland
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De Camilli A, Fischer G. Novel Cellular and Immunotherapy: Toxicities and Perioperative Implications. Curr Oncol 2023; 30:7638-7653. [PMID: 37623035 PMCID: PMC10453139 DOI: 10.3390/curroncol30080554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/09/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 08/26/2023] Open
Abstract
Targeted cellular and immunotherapies have welcomed a new chapter in multi-modal cancer therapy. These agents harness our innate immune system and destroy malignant cells in a precise way as compared with "legacy" chemotherapeutic agents that largely rely on abolishing cell division. New therapies can augment the T-cell recognition of tumor antigens and effectively prevent tumor cells from their historically successful ability to evade immune recognition. These novel agents cause acute and chronic toxicities to a variety of organ systems (enteritis, pneumonitis, hypophysitis, and hepatitis), and this may masquerade as other chronic illnesses or paraneoplastic effects. As the perioperative footprint of cancer patients increases, it is essential that perioperative providers-anesthesiologists, surgeons, nurse anesthetists, and inpatient hospital medicine providers-be up to date on the physiologic mechanisms that underlie these new therapies as well as their acute and subacute toxicity profiles. Immunotherapy toxicity can significantly impact perioperative morbidity as well as influence perioperative management, such as prophylaxis for adrenal insufficiency, preoperative pulmonary assessment, and screening for thyroid dysfunction, among others.
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Affiliation(s)
| | - Gregory Fischer
- Memorial Sloan Kettering, 1275 York Avenue, New York, NY 10065, USA
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Lehmann LH, Heckmann MB, Bailly G, Finke D, Procureur A, Power JR, Stein F, Bretagne M, Ederhy S, Fenioux C, Hamwy O, Funck-Brentano E, Romano E, Pieroni L, Münster J, Allenbach Y, Anquetil C, Leonard-Louis S, Palaskas NL, Hayek SS, Katus HA, Giannitsis E, Frey N, Kaya Z, Moslehi J, Prifti E, Salem JE. Cardiomuscular Biomarkers in the Diagnosis and Prognostication of Immune Checkpoint Inhibitor Myocarditis. Circulation 2023; 148:473-486. [PMID: 37317858 PMCID: PMC10527069 DOI: 10.1161/circulationaha.123.062405] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [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] [Received: 03/01/2023] [Accepted: 05/19/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are approved for multiple cancers but can result in ICI-associated myocarditis, an infrequent but life-threatening condition. Elevations in cardiac biomarkers, specifically troponin-I (cTnI), troponin-T (cTnT), and creatine kinase (CK), are used for diagnosis. However, the association between temporal elevations of these biomarkers with disease trajectory and outcomes has not been established. METHODS We analyzed the diagnostic accuracy and prognostic performances of cTnI, cTnT, and CK in patients with ICI myocarditis (n=60) through 1-year follow-up in 2 cardio-oncology units (APHP Sorbonne, Paris, France and Heidelberg, Germany). A total of 1751 (1 cTnT assay type), 920 (4 cTnI assay types), and 1191 CK sampling time points were available. Major adverse cardiomyotoxic events (MACE) were defined as heart failure, ventricular arrhythmia, atrioventricular or sinus block requiring pacemaker, respiratory muscle failure requiring mechanical ventilation, and sudden cardiac death. Diagnostic performance of cTnI and cTnT was also assessed in an international ICI myocarditis registry. RESULTS Within 72 hours of admission, cTnT, cTnI, and CK were increased compared with upper reference limits (URLs) in 56 of 57 (98%), 37 of 42 ([88%] P=0.03 versus cTnT), and 43 of 57 ([75%] P<0.001 versus cTnT), respectively. This increased rate of positivity for cTnT (93%) versus cTnI ([64%] P<0.001) on admission was confirmed in 87 independent cases from an international registry. In the Franco-German cohort, 24 of 60 (40%) patients developed ≥1 MACE (total, 52; median time to first MACE, 5 [interquartile range, 2-16] days). The highest value of cTnT:URL within the first 72 hours of admission performed best in terms of association with MACE within 90 days (area under the curve, 0.84) than CK:URL (area under the curve, 0.70). A cTnT:URL ≥32 within 72 hours of admission was the best cut-off associated with MACE within 90 days (hazard ratio, 11.1 [95% CI, 3.2-38.0]; P<0.001), after adjustment for age and sex. cTnT was increased in all patients within 72 hours of the first MACE (23 of 23 [100%]), whereas cTnI and CK values were less than the URL in 2 of 19 (11%) and 6 of 22 (27%) of patients (P<0.001), respectively. CONCLUSIONS cTnT is associated with MACE and is sensitive for diagnosis and surveillance in patients with ICI myocarditis. A cTnT:URL ratio <32 within 72 hours of diagnosis is associated with a subgroup at low risk for MACE. Potential differences in diagnostic and prognostic performances between cTnT and cTnI as a function of the assays used deserve further evaluation in ICI myocarditis.
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Affiliation(s)
- Lorenz H. Lehmann
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Markus B. Heckmann
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Guillaume Bailly
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Daniel Finke
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Adrien Procureur
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - John R. Power
- University of California San Diego, San Diego, California, USA
| | - Frederic Stein
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Marie Bretagne
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Stephane Ederhy
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris,, INSERM, Department of Cardiology, CIC-1901, UNICO-GRECO Cardio-oncology program, Saint-Antoine Hospital, Paris, France
| | - Charlotte Fenioux
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | - Omar Hamwy
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
| | | | - Emanuela Romano
- Center for Cancer Immunotherapy, Department of Oncology, PSL Research University, Institut Curie, Paris, France
| | - Laurence Pieroni
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Biochimie- Hormonologie, Hôpital Tenon, Paris, France
| | - Jan Münster
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Yves Allenbach
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of internal medecine, Hôpital Pitié-Salpêtrière, Paris, France
| | - Céline Anquetil
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of internal medecine, Hôpital Pitié-Salpêtrière, Paris, France
| | - Sarah Leonard-Louis
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Neuropathology, Hôpital Pitié-Salpêtrière, F-75013 Paris, France
| | - Nicolas L. Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | | | - Salim S. Hayek
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI
| | - Hugo A. Katus
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Ziya Kaya
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Heidelberg/Mannheim partner site, Heidelberg, Germany
| | - Javid Moslehi
- Section of Cardio-Oncology & Immunology, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Edi Prifti
- IRD, Sorbonne University, UMMISCO, 32 Avenue Henri Varagnat, F-93143 Bondy, France; Sorbonne Université, INSERM (NutriOmics), Paris, France
| | - Joe-Elie Salem
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Pharmacology, CIC-1901, UNICO-GRECO Cardio-oncology program, Pitié-salpétrière Hospital, Paris, France
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Turker I, Johnson DB. Immune checkpoint inhibitor-related myocarditis: current understanding and potential diagnostic and therapeutic strategies. Expert Opin Drug Saf 2023; 22:909-919. [PMID: 37647330 PMCID: PMC10530188 DOI: 10.1080/14740338.2023.2254218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/10/2023] [Revised: 07/31/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Myocarditis associated with immune checkpoint inhibitors presents with an often-severe clinical phenotype with arrhythmias and concurrent myositis. This condition tends to occur early after treatment onset and is associated with a high fatality rate. Diagnosis may be challenging, and treatment algorithms are still evolving. AREAS COVERED This review will provide an overview of immune checkpoint inhibitor mechanism of action and how it relates to myocarditis pathophysiology, diagnostic algorithms and potential pitfalls, and emerging treatment approaches published until May 2023. We will focus on the state of the field and potential new directions in research and patient care. We will also provide consensus-based diagnostic and therapeutic algorithms endorsed by major societies. EXPERT OPINION The field needs more evidence-based approaches to risk stratification so that therapy can be tailored toward less cardiotoxic alternatives in high-risk patients. For diagnostic and therapeutic approaches, data from animal models are unlikely to provide conclusive evidence given the complexity of the human immune system. We strongly invite practitioners in the field to contribute every case to the ongoing multicenter registries.
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Affiliation(s)
- Isik Turker
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, Missouri, MO, USA
| | - Douglas B. Johnson
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, TN, USA
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Matsumori A. Myocarditis and Autoimmunity. Expert Rev Cardiovasc Ther 2023. [PMID: 37243585 DOI: 10.1080/14779072.2023.2219895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/20/2023] [Accepted: 05/26/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Autoimmune myocarditis may develop due to heterogeneous causes. Myocarditis is often caused by viral infections, but it can also be caused by systemic autoimmune diseases. Immune checkpoint inhibitors and virus vaccines induce immune activation, and they can cause the development of myocarditis, as well as several immune-related adverse events. The development of myocarditis is dependent on the genetic factors of the host, and the major histocompatibility complex (MHC) may be an important determinant of the type and severity of the disease. However, non-MHC immunoregulatory genes may also play a role in determining susceptibility. AREA COVERED This review summarizes the current knowledge of the etiology, pathogenesis, diagnosis and treatment of autoimmune myocarditis with a particular focus on viral infection and autoimmunity, and biomarkers of myocarditis. EXPERT OPINION An endomyocardial biopsy may not be the gold standard for the diagnosis of myocarditis. Cardiac magnetic resonance imaging is useful in diagnosing autoimmune myocarditis. Recently identified biomarkers of inflammation and myocyte injury are promising for the diagnosis of myocarditis when measured simultaneously. Future treatments should focus on the appropriate diagnosis of the etiologic agent, as well as on the specific stage of the evolution of immune and inflammatory processes.
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Affiliation(s)
- Akira Matsumori
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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Kersten J. Cardiovascular magnetic resonance imaging in COVID-19 patients: An important tool in everyday clinical practice. J Clin Ultrasound 2023; 51:622-623. [PMID: 36706020 DOI: 10.1002/jcu.23415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 05/03/2023]
Affiliation(s)
- Johannes Kersten
- Division of Sports and Rehabilitation Medicine, University Hospital of Ulm, Ulm, Germany
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Chen YC, Jaffer M, Zhou L, Moslehi J, Forsyth PA, Fecher LA. A Brain, A Heart, and the Courage: Balancing Benefit and Toxicity of Immunotherapy in Melanoma. Am Soc Clin Oncol Educ Book 2023; 43:e390594. [PMID: 37229626 DOI: 10.1200/edbk_390594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The overall survival of advanced melanoma has improved dramatically. Immunotherapies, specifically checkpoint inhibitors, have played a large role in this improvement. These agents have also shown benefit in the adjuvant setting, are approved for treatment of resected stage II, III, and IV melanoma, and play an evolving role in the neoadjuvant setting. Although generally well tolerated, immune-related adverse events occur and can be severe. Here we focus on some severe and potentially long term toxicities, including cardiovascular and neurologic toxicities. Our understanding of the acute and long-term toxicities of immune checkpoint inhibitors continues to evolve. Oncologists must continue to balance cancer risk and treatment-related toxicities.
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Affiliation(s)
- Yen-Chou Chen
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
- Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Muhammad Jaffer
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
| | - Lylybell Zhou
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Javid Moslehi
- Section of Cardio-Oncology and Immunology, Cardiovascular Research Institute (CVRI), University of California, San Francisco (UCSF), San Francisco, CA
| | - Peter A Forsyth
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL
- Department of Oncology, Moffitt Cancer Center and University of South Florida, Tampa, FL
| | - Leslie A Fecher
- Rogel Cancer Center at the University of Michigan, Ann Arbor, MI
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Coustal C, Vanoverschelde J, Quantin X, Lesage C, Michot JM, Lappara A, Ederhy S, Assenat E, Faure M, Issa N, Lambotte O, Puyade M, Dereure O, Tosi D, Rullier P, Serre I, Larcher R, Klouche K, Chanques G, Vernhet-Kovacsik H, Faillie JL, Agullo A, Roubille F, Guilpain P, Maria ATJ. Prognosis of immune checkpoint inhibitors-induced myocarditis: a case series. J Immunother Cancer 2023; 11:jitc-2022-004792. [PMID: 37258037 DOI: 10.1136/jitc-2022-004792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) have transformed cancer treatment over the last decade. Alongside this therapeutic improvement, a new variety of side effects has emerged, called immune-related adverse events (irAEs), potentially affecting any organ. Among these irAEs, myocarditis is rare but life-threatening. METHODS We conducted a multicenter cross-sectional retrospective study with the aim of better characterizing ICI-related myocarditis. Myocarditis diagnosis was based on the recent consensus statement of the International Cardio-Oncology Society. RESULTS Twenty-nine patients were identified, from six different referral centers. Most patients (55%) were treated using anti-programmed-death 1, rather than ICI combination (35%) or anti-programmed-death-ligand 1 (10%). Transthoracic echocardiography was abnormal in 52% of them, and cardiac magnetic resonance showed abnormal features in 14/24 patients (58%). Eleven patients (38%) were classified as severe. Compared with other patients, they had more frequently pre-existing systemic autoimmune disease (45% vs 6%, p=0.018), higher troponin level on admission (42-fold the upper limit vs 3.55-fold, p=0.001), and exhibited anti-acetylcholine receptor autoantibodies (p=0.001). Seven patients (24%) had myocarditis-related death, and eight more patients died from cancer progression during follow-up. Twenty-eight patients received glucocorticoids, 10 underwent plasma exchanges, 8 received intravenous immunoglobulins, and 5 other immunosuppressants. ICI rechallenge was performed in six patients, with only one myocarditis relapse. DISCUSSION The management of ICI-related myocarditis may be challenging and requires a multidisciplinary approach. Prognostic features are herein described and may help to allow ICI rechallenge for some patients with smoldering presentation, after an accurate evaluation of benefit-risk balance.
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Affiliation(s)
- Cyrille Coustal
- Department of Internal Medicine, CHRU de Montpellier, Montpellier, France
| | | | - Xavier Quantin
- Department of thoracic oncology, Regional Cancer Centre Val d'Aurelle - Paul Lamarque, Montpellier, France
| | - Candice Lesage
- Department of Dermatology, CHRU de Montpellier, Montpellier, France
| | | | | | - Stephane Ederhy
- Cardiology, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Eric Assenat
- Department of Oncology, CHRU de Montpellier, Montpellier, France
| | - Maxime Faure
- Department of Interventional Cardiology, CHU de Bordeaux Hôpital Cardiologique, Pessac, France
| | - Nahema Issa
- Intensive Care Unit, CHU de Bordeaux, Bordeaux, France
| | - Olivier Lambotte
- Department of Internal Medicine, CHU Bicêtre, Le Kremlin-Bicetre, France
| | - Mathieu Puyade
- Medecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- CIC-1402, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Olivier Dereure
- Department of Dermatology, CHRU de Montpellier, Montpellier, France
| | - Diego Tosi
- Medical Oncology Department, Institut régional du Cancer de Montpellier, Montpellier, France
| | - Patricia Rullier
- Department of Internal Medicine, CHRU de Montpellier, Montpellier, France
| | - Isabelle Serre
- Department of Pathology, CHRU de Montpellier, Montpellier, France
| | - Romaric Larcher
- Department of Intensive Care Medicine, CHRU de Montpellier, Montpellier, France
| | - Kada Klouche
- Department of Intensive Care Medicine, CHRU de Montpellier, Montpellier, France
| | - Gérald Chanques
- Department of Anesthesiology and Critical Care Medicine, CHRU de Montpellier, Montpellier, France
| | | | - Jean-Luc Faillie
- Department of Medical Pharmacology and Toxicology, University Hospital Centre Montpellier, Montpellier, France
| | - Audrey Agullo
- Department of Cardiology, CHRU de Montpellier, Montpellier, France
| | | | - Philippe Guilpain
- Department of Internal Medicine, CHRU de Montpellier, Montpellier, France
- U1183, Institut national de la santé et de la recherche médicale, Paris, France
| | - Alexandre Thibault Jacques Maria
- Department of Internal Medicine, CHRU de Montpellier, Montpellier, France
- U1183, Institut national de la santé et de la recherche médicale, Paris, France
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