1
|
Kappel C, Abdel-Qadir H, Nadler MB. Pumping Up the Standards: A Call for Improved Cardiovascular Event Reporting in Oncology Trials. JACC CardioOncol 2024; 6:280-282. [PMID: 38774007 PMCID: PMC11103042 DOI: 10.1016/j.jaccao.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024] Open
Affiliation(s)
- Coralea Kappel
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Women’s College Hospital and Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Michelle B. Nadler
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
2
|
de Jesus M, Chanda A, Grabauskas T, Kumar M, Kim AS. Cardiovascular disease and lung cancer. Front Oncol 2024; 14:1258991. [PMID: 38410099 PMCID: PMC10896114 DOI: 10.3389/fonc.2024.1258991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/19/2024] [Indexed: 02/28/2024] Open
Abstract
Lung cancer is the second most common cancer worldwide and the leading cause of cancer-related death. While survival rates have improved with advancements in cancer therapeutics, additional health challenges have surfaced. Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in patients with lung cancer. CVD and lung cancer share many risk factors, such as smoking, hypertension, diabetes, advanced age, and obesity. Optimal management of this patient population requires a full understanding of the potential cardiovascular (CV) complications of lung cancer treatment. This review outlines the common shared risk factors, the spectrum of cardiotoxicities associated with lung cancer therapeutics, and prevention and management of short- and long-term CVD in patients with non-small cell (NSCLC) and small cell (SCLC) lung cancer. Due to the medical complexity of these patients, multidisciplinary collaborative care among oncologists, cardiologists, primary care physicians, and other providers is essential.
Collapse
Affiliation(s)
- Mikhail de Jesus
- Department of Cardiology, University of Connecticut Hartford Hospital, Hartford, CT, United States
| | - Anindita Chanda
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, United States
| | - Titas Grabauskas
- University of Connecticut School of Medicine, Farmington, CT, United States
| | - Manish Kumar
- Department of Cardiology, Pat & Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, United States
| | - Agnes S Kim
- Department of Cardiology, Pat & Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, United States
| |
Collapse
|
3
|
Vergara A, De Felice M, Cesaro A, Gragnano F, Pariggiano I, Golia E, De Pasquale A, Blasi E, Fimiani F, Monda E, Limongelli G, Calabrò P. Immune-Checkpoint Inhibitor-Related Myocarditis: Where We Are and Where We Will Go. Angiology 2023:33197231201929. [PMID: 37699402 DOI: 10.1177/00033197231201929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are specific monoclonal antibodies directed against inhibitory targets of the immune system, mainly represented by programmed death-1 (PD1) ligand-1 (PD-L1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4), thus enabling an amplified T-cell-mediated immune response against cancer cells. These drugs have significantly improved prognosis in patients with advanced metastatic cancer (e.g., melanoma, non-small cell lung cancer, renal cell carcinoma). However, uncontrolled activation of anti-tumor T-cells could trigger an excessive immune response, possibly responsible for multi-organ damage, including, among others, lymphocytic myocarditis. The incidence of ICIs-induced myocarditis is underestimated and the patients affected are poorly characterized. The diagnosis and management of this condition are mainly based on expert opinion and case reports. EKG and ultrasound are tests that can help identify patients at risk of myocarditis during treatment by red flags, such as QRS complex enlargement and narrowing of global longitudinal strain (GLS). Therapy of ICI-related myocarditis is based on immunosuppressors, monoclonal antibodies and fusion proteins. A future strategy could involve the use of microRNAs. This review considers the current state of the art of immune-related adverse cardiovascular events, focusing on histological and clinical features, diagnosis and management, including current treatments and future pharmacological targets.
Collapse
Affiliation(s)
- Andrea Vergara
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Marco De Felice
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Caserta, Italy
- Division of Oncology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Ivana Pariggiano
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Enrica Golia
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Antonio De Pasquale
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Ettore Blasi
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Diseases, A.O.R.N. Dei Colli "V. Monaldi", Naples, Italy
| | - Emanuele Monda
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Unit of Inherited and Rare Cardiovascular Diseases, A.O.R.N. Dei Colli "V. Monaldi", Naples, Italy
| | - Giuseppe Limongelli
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Unit of Inherited and Rare Cardiovascular Diseases, A.O.R.N. Dei Colli "V. Monaldi", Naples, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta, Italy
| |
Collapse
|
4
|
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] [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.
Collapse
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
| |
Collapse
|
5
|
Mei H, Wen W, Fang K, Xiong Y, Liu W, Wang J, Wan R. Immune checkpoint inhibitor-induced myocarditis and myositis in liver cancer patients: A case report and literature review. Front Oncol 2023; 12:1088659. [PMID: 36713559 PMCID: PMC9876740 DOI: 10.3389/fonc.2022.1088659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/23/2022] [Indexed: 01/13/2023] Open
Abstract
With the development of immunotherapy, immune checkpoint inhibitors (ICIs) are widely used in clinical oncology and have achieved good results. ICIs could induce immune-related adverse events (irAEs) in cancer treatment, which warrant sufficient attention. Among them, immune myositis can manifest severe symptoms affecting the whole body, and immune myocarditis occurs with a low incidence but high fatality rate. Here we report a case of grade 3/4 adverse reactions in a patient with partial hepatectomy for malignancy after using ICIs and describe the clinical presentation, laboratory results, treatment, and prognosis. It emphasizes that clinicians should focus on being alert to irAEs in liver cancer patients who have received ICI therapy. The case we present is a 56-year-old male diagnosed with hepatocellular carcinoma. Right hepatic lobectomy was performed in April 2019. Postoperative follow-up showed that transcatheter arterial chemoembolization (TACE) combined with sorafenib (400 mg twice daily) failed to stop the recurrence of the tumor. In December 2020, the patient started to use Camrelizumab injections (200mg/injection every 21 days as a cycle). After 3 cycles, the patient had decreased muscle strength in both lower extremities with chest tightness, dyspnea, and expectoration (whitish sputum). The diagnosis was ICIs injection-induced immune myocarditis and myositis accompanied. The patient's condition improved considerably by steroid pulse therapy timely. The case emphasizes that clinicians should focus on being alert to irAEs in liver cancer patients who have received ICI therapy.
Collapse
Affiliation(s)
- Haoran Mei
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wu Wen
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Kang Fang
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuanpeng Xiong
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Weiqi Liu
- Department of General Surgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Jie Wang
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Renhua Wan
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China,*Correspondence: Renhua Wan,
| |
Collapse
|
6
|
Thavendiranathan P, Sacher A. A New Risk Factor for Cardiovascular Events in Patients Receiving Immune Checkpoint Inhibitor Therapy? JACC CardioOncol 2022; 4:670-672. [PMID: 36636452 PMCID: PMC9830213 DOI: 10.1016/j.jaccao.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Paaladinesh Thavendiranathan
- Department of Medicine, Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada,Address for correspondence: Dr Paaladinesh Thavendiranathan, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, 585 University Avenue, Toronto, Ontario M5G2 2N2, Canada. @dineshpmcc1
| | - Adrian Sacher
- Department of Medicine, Division of Medical Oncology, Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Rini BI, Moslehi JJ, Bonaca M, Schmidinger M, Albiges L, Choueiri TK, Motzer RJ, Atkins MB, Haanen J, Mariani M, Wang J, Hariharan S, Larkin J. Prospective Cardiovascular Surveillance of Immune Checkpoint Inhibitor-Based Combination Therapy in Patients With Advanced Renal Cell Cancer: Data From the Phase III JAVELIN Renal 101 Trial. J Clin Oncol 2022; 40:1929-1938. [PMID: 35239416 PMCID: PMC9177241 DOI: 10.1200/jco.21.01806] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Both immune checkpoint inhibitors (ICIs) and vascular endothelial growth factor receptor (VEGFR) inhibitors are approved for advanced renal cell carcinoma treatment and can cause cardiovascular events (CVs); thus, combination therapy could lead to major adverse CV events (MACE). Cardiac serum biomarker assessment and imaging, including left ventricular ejection fraction (LVEF) monitoring, can be used to evaluate MACE. METHODS To our knowledge, the JAVELIN Renal 101 trial, assessing avelumab plus axitinib versus sunitinib in patients with advanced renal cell carcinoma, is the first randomized study of ICI plus VEGFR inhibitor treatment to include prospective serial cardiac monitoring of LVEF and serum cardiac biomarkers. RESULTS MACE (defined as grade ≥ 3 CV AEs) occurred in 31 patients (7.1%) in the combination arm and 17 patients (3.9%) in the sunitinib arm. Patients in the combination arm who had high baseline troponin T values were at higher risk of MACE versus patients with low values (MACE in 6/35 v 7/135, respectively; relative risk, 3.31; 95% CI, 1.19 to 9.22). This association was not observed in patients treated with sunitinib. Other CV baseline risk factors and serum cardiac biomarkers were not significantly predictive for MACE, although a trend toward an association with dyslipidemia was seen in the combination arm. No clinical value of on-treatment routine monitoring of LVEF in relation to MACE was observed. Although LVEF decline was significantly more frequent in the combination arm, most patients recovered, and decline was not associated with other significant cardiac events or symptoms. CONCLUSION Patients with high baseline troponin T levels receiving ICI and VEGFR combinations may need to be monitored more closely for MACE. Routine monitoring of LVEF in asymptomatic patients is not recommended.
Collapse
Affiliation(s)
- Brian I Rini
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Javid J Moslehi
- Section of Cardio-Oncology & Immunology, Division of Cardiology, Cardiovascular Research Institute, University of California San Francisco School of Medicine, San Francisco, CA.,Vanderbilt University Medical Center, Nashville, TN
| | - Marc Bonaca
- Colorado Prevention Center Clinical Research, Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Manuela Schmidinger
- Department of Urology and Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel, Vienna, Austria
| | - Laurence Albiges
- Medical Oncology Department, Institut Gustave Roussy, Villejuif, France
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | | | | | - John Haanen
- Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | | | | | - James Larkin
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
8
|
Immune Checkpoint Inhibitors-Associated Cardiotoxicity. Cancers (Basel) 2022; 14:cancers14051145. [PMID: 35267453 PMCID: PMC8909315 DOI: 10.3390/cancers14051145] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 12/19/2022] Open
Abstract
Large population-based studies examining differences in ICI-associated cardiotoxicity across cancer types and agents are limited. Data of 5518 cancer patients who received at least one cycle of ICIs were extracted from a large network of health care organizations. ICI treatment groups were classified by the first ICI agent(s) (ipilimumab, nivolumab, pembrolizumab, cemiplimab, avelumab, atezolizumab, or durvalumab) or its class (PD-1 inhibitors, PD-L1 inhibitors, CTLA4-inhibitors, or their combination (ipilimumab + nivolumab)). Time to first cardiac adverse event (CAE) (arrhythmia, acute myocardial infarction, myocarditis, cardiomyopathy, or pericarditis) developed within one year after ICI initiation was analyzed using a competing-risks regression model adjusting for ICI treatment groups, patient demographic and clinical characteristics, and cancer sites. By month 12, 12.5% developed cardiotoxicity. The most common cardiotoxicity was arrhythmia (9.3%) and 2.1% developed myocarditis. After adjusting for patient characteristics and cancer sites, patients who initiated on monotherapy with ipilimumab (adjusted Hazard Ratio (aHR): 2.00; 95% CI: 1.49−2.70; p < 0.001) or pembrolizumab (aHR: 1.21; 95% CI: 1.01−1.46; p = 0.040) had a higher risk of developing CAEs within one year compared to nivolumab monotherapy. Ipilimumab and pembrolizumab use may increase the risk of cardiotoxicity compared to other agents. Avelumab also estimated a highly elevated risk (aHR: 1.92; 95% CI: 0.85−4.34; p = 0.117) compared to nivolumab and other PD-L1 agents, although the estimate did not reach statistical significance, warranting future studies.
Collapse
|
9
|
Delombaerde D, Vervloet D, Franssen C, Croes L, Gremonprez F, Prenen H, Peeters M, Vulsteke C. Clinical implications of isolated troponinemia following immune checkpoint inhibitor therapy. ESMO Open 2021; 6:100216. [PMID: 34271309 PMCID: PMC8287144 DOI: 10.1016/j.esmoop.2021.100216] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/18/2021] [Accepted: 06/28/2021] [Indexed: 01/27/2023] Open
Abstract
Cardiovascular adverse events induced by immune checkpoint inhibitors (ICIs) have gained significant interest over the past decade due to their impact on short- and long-term outcomes. They were initially thought to be rare, but the increasing use of ICIs in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in their incidence. Different guidelines have proposed screening measures for ICI-induced myocarditis by incorporating troponin measurements at baseline and during the first few weeks of treatment. However, no specific guidelines have been developed yet regarding the interpretation of an asymptomatic rise in troponins. This state-of-the art review aims to provide an overview of the clinical relevance of elevated troponins during checkpoint inhibition and recommendations on how to manage elevated troponin levels during ICI therapy.
Collapse
Affiliation(s)
- D Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium.
| | - D Vervloet
- Department of Cardiology, AZ Maria Middelares, Ghent, Belgium
| | - C Franssen
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - L Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
| | - F Gremonprez
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - H Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - M Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium; Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, Edegem, Belgium
| | - C Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Wilrijk, Belgium
| |
Collapse
|
10
|
Lehmann LH, Cautela J, Palaskas N, Baik AH, Meijers WC, Allenbach Y, Alexandre J, Rassaf T, Müller OJ, Aras M, Asnani AH, Deswal A, Laufer-Perl M, Thuny F, Kerneis M, Hayek SS, Ederhy S, Salem JE, Moslehi JJ. Clinical Strategy for the Diagnosis and Treatment of Immune Checkpoint Inhibitor-Associated Myocarditis: A Narrative Review. JAMA Cardiol 2021; 6:1329-1337. [PMID: 34232253 DOI: 10.1001/jamacardio.2021.2241] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance In the last decade, immune checkpoint inhibitors (ICIs) have been approved for the treatment of many cancer types. Immune checkpoint inhibitor-associated myocarditis has emerged as a significant and potentially fatal adverse effect. Recognizing, diagnosing, and treating ICI-associated myocarditis poses new challenges for the practicing clinician. Here, the current literature on ICI-associated myocarditis is reviewed. Observations Clinical presentation and cardiac pathological findings are highly variable in patients with ICI-associated myocarditis. Although endomyocardial biopsy is the criterion standard diagnostic test, a combination of clinical suspicion, cardiac biomarkers (specifically troponin), and cardiac imaging, in addition to biopsy, is often needed to support the diagnosis. Importantly, the combination of a cytotoxic T-lymphocyte-associated protein 4 inhibitor with a programmed cell death protein 1 or programmed death-ligand 1 inhibitor increases the risk of developing ICI-associated myocarditis. Conclusion and Relevance This review aims to provide a standardized diagnostic and therapeutic approach for patients with suspected ICI-associated myocarditis. A complete history of recent cancer treatments and physical examination in combination with cardiac biomarkers, cardiac imaging, and endomyocardial biopsy represent a pragmatic diagnostic approach for most cases of ICI-associated myocarditis. The addition of novel biomarkers or imaging modalities is an area of active research and should be evaluated in larger cohorts.
Collapse
Affiliation(s)
- Lorenz H Lehmann
- Department of Cardiology, Angiology, and Pneumology, Cardio-Oncology Unit, Heidelberg University Hospital, Heidelberg, Germany.,German Centre for Cardiovascular Research, partner site Heidelberg/Mannheim, Heidelberg, Germany.,German Cancer Research Centre, Heidelberg, Germany
| | - Jennifer Cautela
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, France.,Groupe Méditerranéen de Cardio-Oncologie, Marseille, France.,Oncosafety Network of the Early Phases Cancer Trials Center, Marseille, France
| | - Nicolas Palaskas
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Alan H Baik
- Department of Medicine, Division of Cardiology, University of California, San Francisco
| | - Wouter C Meijers
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France.,Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Association Institut de Myologie, Centre de Recherche en Myologie, UMRS974, Paris, France
| | - Joachim Alexandre
- Department of Pharmacology, Normandie University, University of Caen Normandy, PICARO Cardio-oncology Program, Signalisation, Électrophysiologie et Imagerie des Lésions d'Ischémie-Reperfusion Myocardique, Caen, France
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver J Müller
- Department of Internal Medicine III, University of Kiel, Kiel, Germany.,German Center for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Mandar Aras
- Department of Medicine, Division of Cardiology, University of California, San Francisco
| | - Aarti H Asnani
- CardioVascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anita Deswal
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Michal Laufer-Perl
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Franck Thuny
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, France.,Groupe Méditerranéen de Cardio-Oncologie, Marseille, France
| | - Mathieu Kerneis
- Sorbonne Université, ACTION Study Group, Institut National de la Santé et de la Recherche Médicale, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Stéphane Ederhy
- Hôpitaux Universitaires Paris-Est, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Service de Cardiologie, Unico, Unité de Cardio-Oncologie, Groupe de Recherche Clinique en Cardio-Oncologie, Université Pierre et Marie Curie, Paris, France
| | - Joe-Elie Salem
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, UNICO-GRECO Cardio-Oncology Program, Pitié-Salpêtrière Hospital, Paris, France
| | - Javid J Moslehi
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
11
|
Zarifa A, Kim JW, Lopez-Mattei J, Palaskas N, Iliescu C, Kim PY. Cardiac Toxicities Associated with Immune Checkpoints Inhibitors: Mechanisms, Manifestations and Management. Korean Circ J 2021; 51:579-597. [PMID: 34227272 PMCID: PMC8263294 DOI: 10.4070/kcj.2021.0089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/02/2021] [Accepted: 05/07/2021] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) associated cardiovascular adverse events (CVAE) have become more frequent with the growing use of cancer immunotherapy. CVAEs include a wide spectrum of diseases such as myocarditis, pericarditis, heart failure, arrhythmias, coronary artery disease, and hypertension. The induction of cardiovascular side effects by ICI use is hypothesized to occur due to inflammation and immune dysregulation of normal tissue in response to immunotherapy. Management of ICI-associated CVAEs mitigates an overactive immune response by utilizing steroids, immunomodulatory drugs and hemodynamic stabilization. However, few controlled studies on the cardiovascular safety of ICIs exist and treatment of their side effects are mostly from limited case series. Our review seeks to provide the most recent understanding of ICI-associated CVAEs and their management.
Collapse
Affiliation(s)
- Abdulrazzak Zarifa
- Department of Medicine, Brookdale Hospital University and Medical Center, Brooklyn, NY, USA
| | - Jin Wan Kim
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Juan Lopez-Mattei
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicolas Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cezar Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter Y Kim
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
12
|
Frayberg M, Yung A, Zubiri L, Zlotoff DA, Reynolds KL. What the Cardiologist Needs to Know About Cancer Immunotherapies and Complications. Curr Treat Options Oncol 2021; 22:53. [PMID: 34037918 DOI: 10.1007/s11864-021-00844-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT Immunotherapies have transformed the current landscape for cancer treatment and demonstrated unparalleled improvements in survival rates. Now, a third of cancer patients are eligible for treatment with the most widely used class of immunotherapy, immune checkpoint inhibitors (ICIs). As more patients are treated with these novel agents, it is critical for both oncologists and subspecialists to establish a better understanding of the adverse events which can occur. The incidence of myocarditis associated with ICI therapy has been reported to be between 0.27 and 1.14%, 5 times that of myocarditis from other cancer therapies, and, of those patients, 20-50% develop a fulminant form. However, because of unclear risk factors, a broad clinical spectrum, and lack of specific noninvasive studies for diagnosis, the care of patients with ICI-associated cardiotoxicity can be challenging. Here, we have provided a brief overview of the current immunotherapy agents with a focus on the emerging evidence regarding diagnosis and management of cardiac adverse events.
Collapse
Affiliation(s)
- Marina Frayberg
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anthony Yung
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Leyre Zubiri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel A Zlotoff
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerry L Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
13
|
Ederhy S, Salem JE, Dercle L, Hasan AS, Chauvet-Droit M, Nhan P, Ammari S, Pinna B, Redheuil A, Boussouar S, Champiat S, Soulat-Dufour L, Cohen A. Role of Cardiac Imaging in the Diagnosis of Immune Checkpoints Inhibitors Related Myocarditis. Front Oncol 2021; 11:640985. [PMID: 34055610 PMCID: PMC8158154 DOI: 10.3389/fonc.2021.640985] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/24/2021] [Indexed: 11/13/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) have constituted a paradigm shift in the management of patients with cancer. Their administration is associated with a new spectrum of immune-related toxicities that can affect any organ. In patients treated with ICI, cardiovascular toxicities, particularly myocarditis, occur with a low incidence (<1%) but with a high fatality rate (30-50%). ICI-related myocarditis has been attributed to an immune infiltration, comprising of T-cells that are positive for CD3+, CD4+, CD8+, and macrophages that are positive for CD68. The diagnosis remains challenging and is made based on clinical syndrome, an electrocardiogram (ECG), biomarker data, and imaging criteria. In most clinical scenarios, endomyocardial biopsy plays a pivotal role in diagnosis, while cardiac magnetic resonance imaging (cMRI) has limitations that should be acknowledged. In this review, we discuss the role of medical imaging in optimizing the management of ICI related myocarditis, including diagnosis, prognostication, and treatment decisions.
Collapse
Affiliation(s)
- Stéphane Ederhy
- Department of Cardiology, Sorbonne Université, AP-HP, Saint-Antoine Hospital, Paris, France
- UNICO-GRECO APHP.Sorbonne Cardio-Oncology Program, Sorbonne Université, Paris, France
| | - Joe-Elie Salem
- UNICO-GRECO APHP.Sorbonne Cardio-Oncology Program, Sorbonne Université, Paris, France
- Sorbonne Université, INSERM CIC-1901, AP-HP.Sorbonne, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
- Unité INSERM UMRS-ICAN 1166, Unité de recherche sur les maladies cardiovasculaires, du métabolisme et de la nutrition, Sorbonne Universités, Paris, France
- Division of Medicine and Pharmacology, Cardio-oncology program, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Laurent Dercle
- Department of Radiology, New York Presbyterian, Columbia University Irving Medical Center, New York, NY, United States
| | - Abrar Saqif Hasan
- Department of Internal Medicine, Montefiore/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Marion Chauvet-Droit
- Department of Cardiology, Sorbonne Université, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Pascal Nhan
- Department of Cardiology, Sorbonne Université, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Samy Ammari
- Radiology Department, Gustave Roussy Cancer Campus, Villejuif, France
- BIOMAPS, UMR1281, INSERM.CEA.CNRS, Université Paris-Saclay, Paris, France
| | - Bruno Pinna
- UNICO-GRECO APHP.Sorbonne Cardio-Oncology Program, Sorbonne Université, Paris, France
| | - Alban Redheuil
- LIB Biomedical Imaging Laboratory INSERM, CNRS, ICT Cardiothoracic Imaging Unit & Radiology Department, ICAN Institute of Cardiometabolism and Nutrition, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne Université, Paris, France
| | - Samia Boussouar
- LIB Biomedical Imaging Laboratory INSERM, CNRS, ICT Cardiothoracic Imaging Unit & Radiology Department, ICAN Institute of Cardiometabolism and Nutrition, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne Université, Paris, France
| | - Stephane Champiat
- Drug Development Department (DITEP), Institut Gustave Roussy, Villejuif, France
| | - Laurie Soulat-Dufour
- Department of Cardiology, Sorbonne Université, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Ariel Cohen
- Department of Cardiology, Sorbonne Université, AP-HP, Saint-Antoine Hospital, Paris, France
- UNICO-GRECO APHP.Sorbonne Cardio-Oncology Program, Sorbonne Université, Paris, France
| |
Collapse
|
14
|
Gong FF, Cascino GJ, Murtagh G, Akhter N. Circulating Biomarkers for Cardiotoxicity Risk Prediction. Curr Treat Options Oncol 2021; 22:46. [PMID: 33866434 DOI: 10.1007/s11864-021-00845-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 01/22/2023]
Abstract
OPINION STATEMENT Improvements in cancer survival have led to the emergence of cardiovascular disease as an important determinant of adverse outcome in survivors. Cancer therapeutics-related cardiac dysfunction is the most well-known form of cardiotoxicity. However, newer cancer therapies bring a broader range of cardiotoxicities. The optimal method to identify patients at risk of these complications is unclear, but circulating biomarkers comprise one possible approach. Troponins and natriuretic peptides have garnered the broadest evidence base for cardiotoxicity risk prediction, but other markers are being investigated. In this review, we explore evidence for circulating biomarkers in cardiotoxicity prediction associated with cancer therapies.
Collapse
Affiliation(s)
- Fei Fei Gong
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 600, Chicago, IL, 60611, USA
| | - Gregory J Cascino
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 600, Chicago, IL, 60611, USA
| | - Gillian Murtagh
- Diagnostics Division, Abbott Laboratories, 100 Abbott Park Road, CP1-3, Abbott Park, North Chicago, IL, 60064-6094, USA
| | - Nausheen Akhter
- Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 600, Chicago, IL, 60611, USA.
| |
Collapse
|
15
|
Moslehi J, Lichtman AH, Sharpe AH, Galluzzi L, Kitsis RN. Immune checkpoint inhibitor-associated myocarditis: manifestations and mechanisms. J Clin Invest 2021; 131:145186. [PMID: 33645548 DOI: 10.1172/jci145186] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have transformed the treatment of various cancers, including malignancies once considered untreatable. These agents, however, are associated with inflammation and tissue damage in multiple organs. Myocarditis has emerged as a serious ICI-associated toxicity, because, while seemingly infrequent, it is often fulminant and lethal. The underlying basis of ICI-associated myocarditis is not completely understood. While the importance of T cells is clear, the inciting antigens, why they are recognized, and the mechanisms leading to cardiac cell injury remain poorly characterized. These issues underscore the need for basic and clinical studies to define pathogenesis, identify predictive biomarkers, improve diagnostic strategies, and develop effective treatments. An improved understanding of ICI-associated myocarditis will provide insights into the equilibrium between the immune and cardiovascular systems.
Collapse
Affiliation(s)
- Javid Moslehi
- Division of Cardiovascular Medicine and Division of Oncology, Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew H Lichtman
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Arlene H Sharpe
- Department of Immunology and Blavatnik Institute, Harvard Medical School, Boston, Massachusetts, USA.,Evergrande Center for Immunologic Diseases, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lorenzo Galluzzi
- Department of Radiation Oncology, Sandra and Edward Meyer Cancer Center, Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medical College, New York, New York, USA.,Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA.,Université de Paris, Paris, France
| | - Richard N Kitsis
- Departments of Medicine and Cell Biology, Wilf Family Cardiovascular Research Institute, and Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|
16
|
Immune Checkpoint Inhibitor (ICI)-Related Cardiotoxicity. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1342:377-387. [DOI: 10.1007/978-3-030-79308-1_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
17
|
Ederhy S, Benhamou-Tarallo I, Chauvet-Droit M, Nhan P, Cohen R, Pinna B, Cholet C, Fenioux C, Champiat S, Salem JE, Soulat-Dufour L, Cohen AA. Cardiotoxicity Related to Immune Checkpoint Inhibitors. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00878-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
18
|
Gutierrez C, Rajendram P, Pastores SM. Toxicities Associated with Immunotherapy and Approach to Cardiotoxicity with Novel Cancer Therapies. Crit Care Clin 2020; 37:47-67. [PMID: 33190775 DOI: 10.1016/j.ccc.2020.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In recent years, major advances in oncology especially the advent of targeted agents and immunotherapies (immune checkpoint inhibitors [ICIs] and chimeric antigen receptor [CAR] T-cell therapy) have led to improved quality of life and survival rates in patients with cancer. This article focuses on the clinical features, and grading and management of toxicities associated with ICIs and CAR T-cell therapy. In addition, because cardiotoxicity is one of the most harmful effects of anticancer therapeutics, we describe the risk factors and mechanisms of cardiovascular injury associated with newer agents, screening technologies for at-risk patients, and preventive and treatment strategies.
Collapse
Affiliation(s)
- Cristina Gutierrez
- Department of Critical Care Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Prabalini Rajendram
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, 1275 York Avenue C-1179, New York, NY 10065, USA.
| |
Collapse
|
19
|
Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of immune-mediated cardiovascular, rheumatic, and renal toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6159-6173. [PMID: 32856212 DOI: 10.1007/s00520-020-05710-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as the newest pillar of cancer treatment. Immune-mediated toxicities, stemming from increased activity within the T cell lineage, range from asymptomatic or mild complications to those that are fulminant and potentially fatal. Although they are of variable occurrence, cardiovascular, rheumatic, and renal immune-mediated toxicities are among the most serious of these adverse events. We present MASCC recommendations with respect to the workup and management of cardiovascular, rheumatic, and renal immune-mediated toxicities with a focus on presentations that require treatment with immunomodulating agents.
Collapse
|
20
|
Cohen M, Mustafa S, Elkherpitawy I, Meleka M. A Fatal Case of Pembrolizumab-Induced Myocarditis in Non-Small Cell Lung Cancer. JACC Case Rep 2020; 2:426-430. [PMID: 34317255 PMCID: PMC8311714 DOI: 10.1016/j.jaccas.2019.12.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/26/2019] [Indexed: 01/07/2023]
Abstract
Immune channel inhibitor–induced myocarditis is rare, and its management is challenging. Recently, guidelines were established for all ICIs, yet they do not take into account individual drug toxicities or screening protocols for prevention. We present a rare case of rapidly progressive pembrolizumab-induced fatal myocarditis in an initially asymptomatic patient. (Level of Difficulty: Beginner.)
Collapse
Affiliation(s)
- Max Cohen
- New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York
| | - Saim Mustafa
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Islam Elkherpitawy
- Jersey Shore University Hospital and Medical Center, Neptune, New Jersey
| | - Matthew Meleka
- Jersey Shore University Hospital and Medical Center, Neptune, New Jersey
| |
Collapse
|
21
|
Curigliano G, Lenihan D, Fradley M, Ganatra S, Barac A, Blaes A, Herrmann J, Porter C, Lyon AR, Lancellotti P, Patel A, DeCara J, Mitchell J, Harrison E, Moslehi J, Witteles R, Calabro MG, Orecchia R, de Azambuja E, Zamorano JL, Krone R, Iakobishvili Z, Carver J, Armenian S, Ky B, Cardinale D, Cipolla CM, Dent S, Jordan K. Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations. Ann Oncol 2020; 31:171-190. [PMID: 31959335 PMCID: PMC8019325 DOI: 10.1016/j.annonc.2019.10.023] [Citation(s) in RCA: 488] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/13/2022] Open
Abstract
Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.
Collapse
Affiliation(s)
- G. Curigliano
- European Institute of Oncology IRCCS, Milan
- Department of Oncology and Haematology (DIPO), University of Milan, Milan, Italy
| | - D. Lenihan
- Cardiovascular Division, Cardio-Oncology Center of Excellence, Washington University Medical Center, St. Louis
| | - M. Fradley
- Cardio-oncology Program, Division of Cardiovascular Medicine, Morsani College of Medicine and H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa
| | - S. Ganatra
- Cardio-Oncology Program, Lahey Medical Center, Burlington
| | - A. Barac
- Cardio-Oncology Program, Medstar Heart and Vascular Institute and MedStar Georgetown Cancer Institute, Georgetown University Hospital, Washington DC
| | - A. Blaes
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis
| | | | - C. Porter
- University of Kansas Medical Center, Lawrence, USA
| | - A. R. Lyon
- Royal Brompton Hospital and Imperial College, London, UK
| | - P. Lancellotti
- GIGA Cardiovascular Sciences, Acute Care Unit, Heart Failure Clinic, CHU Sart Tilman, University Hospital of Liège, Liège, Belgium
| | - A. Patel
- Morsani College of Medicine, University of South Florida, Tampa
| | - J. DeCara
- Medicine Section of Cardiology, University of Chicago, Chicago
| | - J. Mitchell
- Washington University Medical Center, St. Louis
| | - E. Harrison
- HCA Memorial Hospital and University of South Florida, Tampa
| | - J. Moslehi
- Vanderbilt University School of Medicine, Nashville
| | - R. Witteles
- Division of Cardiovascular Medicine, Falk CVRC, Stanford University School of Medicine, Stanford, USA
| | - M. G. Calabro
- Department of Anesthesia and Intensive Care, IRCCS, San Raffaele Scientific Institute, Milan, Italy
| | | | - E. de Azambuja
- Institut Jules Bordet and L’Université Libre de Bruxelles, Brussels, Belgium
| | | | - R. Krone
- Division of Cardiology, Washington University, St. Louis, USA
| | - Z. Iakobishvili
- Clalit Health Services, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J. Carver
- Division of Cardiology, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia
| | - S. Armenian
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte
| | - B. Ky
- University of Pennsylvania School of Medicine, Philadelphia, USA
| | - D. Cardinale
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan
| | - C. M. Cipolla
- Cardiology Department, European Institute of Oncology, IRCCS, Milan, Italy
| | - S. Dent
- Duke Cancer Institute, Duke University, Durham, USA
| | - K. Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - ESMO Guidelines Committee
- Correspondence to: ESMO Guidelines Committee, ESMO Head Office, Via Ginevra 4, CH-6900 Lugano, Switzerland, (ESMO Guidelines Committee)
| |
Collapse
|
22
|
Palaskas N, Lopez‐Mattei J, Durand JB, Iliescu C, Deswal A. Immune Checkpoint Inhibitor Myocarditis: Pathophysiological Characteristics, Diagnosis, and Treatment. J Am Heart Assoc 2020; 9:e013757. [PMID: 31960755 PMCID: PMC7033840 DOI: 10.1161/jaha.119.013757] [Citation(s) in RCA: 209] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/03/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Nicolas Palaskas
- Department of CardiologyThe University of Texas MD Anderson Cancer CenterHoustonTX
| | - Juan Lopez‐Mattei
- Department of CardiologyThe University of Texas MD Anderson Cancer CenterHoustonTX
| | - Jean Bernard Durand
- Department of CardiologyThe University of Texas MD Anderson Cancer CenterHoustonTX
| | - Cezar Iliescu
- Department of CardiologyThe University of Texas MD Anderson Cancer CenterHoustonTX
| | - Anita Deswal
- Department of CardiologyThe University of Texas MD Anderson Cancer CenterHoustonTX
- Section of CardiologyMichael E. DeBakey VA Medical CenterBaylor College of MedicineHoustonTX
| |
Collapse
|
23
|
Clinical and Advanced MRI Techniques for Detection of Checkpoint Inhibitor Associated Myocarditis. CURRENT CARDIOVASCULAR IMAGING REPORTS 2020. [DOI: 10.1007/s12410-019-9521-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Abstract
Purpose of Review
With the advent of immune checkpoint inhibitors (ICIs), cancer treatment has been revolutionized; however, these agents are associated with immune-related adverse events, including myocarditis, which ranges from mild to fulminant in severity. Currently, there are no established guidelines in diagnosing ICI-associated myocarditis, and the gold standard test for diagnosis of myocarditis in general is invasive endomyocardial biopsy (EMB). Cardiac magnetic resonance (CMR) imaging is a noninvasive test with the advantage of providing structural, functional and tissue characterization information. Additionally, it provides high spatial and temporal resolution without exposure to ionizing radiation, iodinated contrast, or radioactive isotopes.
Recent Findings
With an increasing number of reported cases of ICI associated myocarditis, understanding of the disease process and associated CMR findings is growing. Diagnostic testing with cardiac biomarkers, electrocardiogram, and echocardiogram can be nonspecific and EMB can have sampling errors. CMR as a diagnostic tool can provide functional assessment of biventricular ejection fraction, myocardial strain, tissue characterization of myocardial edema and inflammation as well as fibrosis. Furthermore, with advanced parametric mapping techniques, CMR provides even more sensitive and quantitative information about myocardial inflammation and fibrosis, including measurements of extracellular volume.
Summary
ICI-associated myocarditis is a serious immune adverse event, and CMR plays a vital role in establishing its diagnosis, providing prognostic information, and has the potential for use as a tool for screening and serial monitoring in patients exposed to ICIs.
Collapse
|
24
|
Lenihan DJ, Fradley MG, Dent S, Brezden-Masley C, Carver J, Filho RK, Neilan TG, Blaes A, Melloni C, Herrmann J, Armenian S, Thavendiranathan P, Armstrong GT, Ky B, Hajjar L. Proceedings From the Global Cardio-Oncology Summit: The Top 10 Priorities to Actualize for CardioOncology. JACC CardioOncol 2019; 1:256-272. [PMID: 34396188 PMCID: PMC8352295 DOI: 10.1016/j.jaccao.2019.11.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/04/2019] [Indexed: 12/27/2022] Open
Abstract
The discipline of cardio-oncology has expanded at a remarkable pace. Recent developments and challenges to clinicians who practice cardio-oncology were presented at the Global Cardio-Oncology Summit on October 3 to 4, 2019, in São Paulo, Brazil. Here, we present the top 10 priorities for our field that were discussed at the meeting, and also detail a potential path forward to address these challenges. Defining robust predictors of cardiotoxicity, clarifying the role of cardioprotection, managing and preventing thromboembolism, improving hematopoietic stem cell transplant outcomes, personalizing cardiac interventions, building the cardio-oncology community, detecting and treating cardiovascular events associated with immunotherapy, understanding tyrosine kinase inhibitor cardiotoxicity, and enhancing survivorship care are all priorities for the field. The path forward requires a commitment to research, education, and excellence in clinical care to improve our patients' lives.
Collapse
Key Words
- CV, cardiovascular
- CVD, cardiovascular disease
- DOAC, direct oral anticoagulant
- GCOS, Global Cardio-Oncology Summit
- GLS, global longitudinal strain
- HCT, hematopoietic cell transplantation
- ICI, immune checkpoint inhibitor
- LVEF, left ventricular ejection fraction
- PD-1, programmed cell death 1 or its ligand
- PD-L1, programmed cell death ligand 1
- TKI, tyrosine kinase inhibitor
- VTE, venous thromboembolism
- anthracycline
- antiangiogenic therapy
- bone marrow transplantation
- breast cancer
- cancer survivorship
- immunotherapy
- thrombosis
- tyrosine kinase inhibitor
Collapse
Affiliation(s)
- Daniel J. Lenihan
- Cardio-Oncology Center of Excellence, Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Michael G. Fradley
- Cardio-Oncology Program, Moffitt Cancer Center, University of South Florida, Tampa, Florida, USA
| | - Susan Dent
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Joseph Carver
- Cardio-Oncology Center of Excellence at the Abramson Cancer Center, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roberto Kalil Filho
- Cardio-Oncology Program, Department of Cardiopneumology, Cancer Institute and Heart Institute, University of São Paulo, Brazil
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Blaes
- Division of Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Saro Armenian
- City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Paaladinesh Thavendiranathan
- Division of Cardiology, Peter Munk Cardiac Centre, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, University of Toronto, Toronto, Canada
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Bonnie Ky
- Cardio-Oncology Center of Excellence at the Abramson Cancer Center, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ludhmila Hajjar
- Cardio-Oncology Program, Department of Cardiopneumology, Cancer Institute and Heart Institute, University of São Paulo, Brazil
| |
Collapse
|
25
|
Li Q, Xi J, Li B, Li N. MiR‐16, as a potential NF‐κB‐related miRNA, exerts anti‐inflammatory effects on LPS‐induced myocarditis via mediating CD40 expression: A preliminary study. J Biochem Mol Toxicol 2019; 34:e22426. [PMID: 31777165 DOI: 10.1002/jbt.22426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/10/2019] [Accepted: 11/14/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Qiang‐Qiang Li
- Department of Cardiology of Integrated Traditional Chinese and Western MedicineAnqiu People's Hospital Weifang Shandong China
| | - Jing Xi
- Department of CardiologyAnqiu People's Hospital Weifang Shandong China
| | - Bing‐Qiang Li
- Department of CardiologyAnqiu People's Hospital Weifang Shandong China
| | - Ning Li
- Department of CardiologyAnqiu People's Hospital Weifang Shandong China
| |
Collapse
|
26
|
Cardiovascular Toxicities of Immune Checkpoint Inhibitors. J Am Coll Cardiol 2019; 74:1714-1727. [PMID: 31558256 DOI: 10.1016/j.jacc.2019.07.079] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/25/2019] [Accepted: 07/31/2019] [Indexed: 12/17/2022]
|
27
|
Abstract
PURPOSE OF REVIEW With the rapid development of novel cancer therapeutics and the growing number of cancer survivors, there is significant demand for cardio-oncology experts to care for these patients. As such, it has become increasingly necessary to develop formalized training in the field of cardio-oncology. This review will focus on the current state of cardio-oncology education, with recommendations for the development of dedicated cardio-oncology fellowships. RECENT FINDINGS Cardio-oncology fellowships should be affiliated with high-volume centers that have established cardio-oncology clinical and research programs with dedicated cardio-oncology faculty. Several recent publications have proposed recommendations to develop uniform cardio-oncology training standards, core curricula, and evaluation metrics. With the rapid evolution of the field and the support of various profession organizations, the number and quality of dedicated cardio-oncology fellowship programs is expected to increase significantly. The adoption of defined training requirements and evaluation standards to measure competency will be essential to ensure the legitimacy and success of the field.
Collapse
Affiliation(s)
- Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Morsani College of Medicine and H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, 12902 USF Magnolia Dr., MCB-CPT, Tampa, FL, 33612-9416, USA.
| |
Collapse
|