Cardiotoxicity Associated with Chemotherapy Used in Gastrointestinal Tumours

Cardiotoxicity in platinum-based chemotherapy: Mechanisms, manifestations, and management

Platinum-based chemotherapy, a cornerstone in the treatment of various malignancies, is often limited by its potential cardiotoxic effects. Understanding these effects is crucial for optimizing patient outcomes and guiding treatment decisions. This review explores the mechanisms, clinical manifestations, detection, management, and future directions in the research of cardiotoxicity associated with platinum-based chemotherapy. The mechanisms discussed here include oxidative stress, reactive oxygen species production, DNA damage, and alterations in signaling pathways. Clinical manifestations range from mild symptoms to severe complications, including Takotsubo cardiomyopathy, as highlighted by recent case studies. The role of diagnostic tools such as echocardiography, cardiac magnetic resonance imaging, and cardiac biomarkers in early detection is emphasized, underscoring the importance of regular cardiac monitoring. Management strategies focus on cardioprotective agents, alternative chemotherapy regimens, and emerging therapeutic approaches, including the potential of nano liposomal and cubosomal formulations. The review also delves into the future of personalized medicine in predicting and managing cardiotoxicity, advocating for ongoing research to mitigate these adverse effects. This comprehensive overview aims to enhance the understanding of cardiotoxicity in platinum-based chemotherapy, informing clinical practices and promoting patient-centric care.

Risk factors for fluorouracil-induced cardiotoxicity in patients with gastrointestinal tumor

Objective

To explore the risk factors for cardiotoxicity in patients with gastrointestinal (GI) tumors treated with fluorouracil drugs.

Methods

This study included patients with GI tumors who received fluorouracil at our hospital between January 2018 and April 2022. The demographic and clinical characteristics were collected. The risk factors associated with the cardiotoxicity of fluorouracil were explored using multivariable logistic regression.

Results

A total of 300 patients were finally included and divided into the cardiotoxicity (n = 81) and non-cardiotoxicity groups (n = 219). The occurrence of fluorouracil-induced cardiotoxicity was higher in patients with hypertension, hyperlipidemia, diabetes mellitus, older age, those treated with capecitabine, and combined radiotherapy. The multivariable logistic regression showed that treatment with capecitabine, history of hyperlipidemia, history of diabetes, older age, and combined radiotherapy were independent risk factors for the cardiotoxicity of fluorouracil.

Conclusion

Hyperlipidemia, diabetes, older age, treatment with capecitabine, and adjuvant radiotherapy might be independent risk factors for the cardiotoxicity of fluorouracil in patients with GI tumors.

Gastrointestinal Cancer Therapy and Cardiotoxicity

OPINION STATEMENT

Gastrointestinal cancers are a heterogenous group of cancers that share common risk factors with cardiovascular disease. Therapy for gastrointestinal cancers have improved cancer-specific outcomes at the cost of cardiotoxicity. The most common cardiotoxic therapies utilized in gastrointestinal cancers include conventional chemotherapy (including fluoropyrimidines and anthracyclines), targeted therapies including anti-vascular endothelial growth factor (VEGF) therapy and tyrosine kinase inhibitors (TKI), and immunotherapy. It is important for clinicians managing patients with gastrointestinal cancers to be aware of potential cardiotoxicity associated with these agents.

Endothelin-based markers for endothelial dysfunction in chemotherapy-induced cardiotoxicity

Current cardiac biomarkers, troponins and brain natriuretic peptide, are primarily used to assist in the diagnosis or exclusion of myocardial damage and congestive heart failure, respectively. The use of these biomarkers in chemotherapy-induced cardiotoxicity has been evaluated by various studies. However, neither biomarker provides early predictive value, leaving many cancer survivors with irreversible cardiac injury. Assessing endothelial dysfunction could be an effective measure of chemotherapy-induced cardiotoxicity at the vascular level. Risk profiling and detection of vascular toxicities may offer predictive biomarkers to prevent chronic manifestation of irreversible cardiotoxicities. Emerging interest has developed in finding biomarkers that could ideally provide earlier prognostic value. Thus, the aim of this review is to give an overview of current blood-based cardiac biomarkers and discuss the potential of endothelin-1 (ET-1) and more stable peptide fragments of ET-1 synthesis as biomarkers of endothelial dysfunction. For instance, endothelin-like domain peptide (ELDP) and C-terminal pro-endothelin-1 (CT-proET-1) demonstrated high-sensitivity and longer clearance rate than ET-1. Thus, investigating their biomarker role in chemotherapy-induced cardiotoxicity is important and could provide additional insights for identifying patients at risk. Also, additional research is required to fully understand ELDP-mediated vasoconstriction. This review will discuss the future development of ET-1, ELDP and CT-proET-1 as prospective predictive biomarkers.

Effectiveness of sacubitril-valsartan in patients with cancer therapy-related cardiac dysfunction: a systematic review of clinical and preclinical studies

INTRODUCTION

Cancer therapy-related cardiac dysfunction (CTRCD) is a critical problem with an impact on both oncological and cardiovascular prognosis, especially when it prevents patients from receiving cancer treatment. However, there are very limited data on the efficacy of sacubitril/valsartan in the prevention and treatment of cardiotoxicity. This systematic review aimed to evaluate the potential benefit of sacubitril/valsartan in patients with CTRCD.

EVIDENCE ACQUISITION

The databases included MEDLINE, Embase, LILACS, Scopus and Cochrane Central up to January 20, 2022. All pre-clinical and clinical studies including observational studies (cohorts, case-control, cross-sectional and case reports) that used sacubitril/valsartan for prevention or treatment of CTRCD. The primary effectiveness endpoints was CTRCD, defined as a clinically significant change in left ventricular ejection fraction (LVEF) at the end of the follow-up.

EVIDENCE SYNTHESIS

And after applying the eligibility criteria, 12 articles (9 in humans and 3 preclinical studies) were included in this systematic review. The 3 preclinical studies demonstrated beneficial effects in preventing, attenuating and/or delaying the onset of myocardial damage at the cellular level, ventricular dysfunction and remodeling. Regardind human studies, most of them were composed of case reports. The largest study consisted of a retrospective multicentric cohort with 64 patients.

CONCLUSIONS

All clinical studies have demonstrated that used Sac/Val in human showed a significant increase in LVEF, and when reported, a reduction in left ventricular volume and NT-proBNP (or BNP). Randomized clinical trials are needed to confirm this hypothesis.

Quantification of Coronary Artery Atherosclerotic Burden and Muscle Mass: Exploratory Comparison of Two Freely Available Software Programs

Coronary artery calcification and sarcopenia may have a relevant prognostic impact in oncological and non-oncological patients. The use of freeware software is promising for quantitative evaluation of these parameters after whole-body positron emission tomography (PET)/computed tomography (CT) and might be useful for one-stop shop risk stratification without additional radiation ionizing burden and further charges to health care costs. In this study, we compared two semiautomatic freeware software tools (Horos Medical Image software and LIFEx) for the assessment of coronary artery calcium (CAC) score and muscle mass in 40 patients undergoing whole-body PET/CT. The muscle areas obtained by the two software programs were comparable, showing high correlation with Lin’s concordance coefficient (0.9997; 95% confidence intervals: 0.9995–0.9999) and very good agreement with Bland–Altman analysis (mean difference = 0.41 cm2, lower limit = −1.06 cm2, upper limit = 1.89) was also found. For CAC score, Lin’s concordance correlation coefficient was 0.9976 (95% confidence intervals: 0.9965–0.9984) and in a Bland–Altman analysis an increasing mean difference from 8 to 78 by the mean values (intercept = −0.050; slope = 0.054; p < 0.001) was observed, with a slight overestimation of Horos CAC score as compared to LIFEx, likely due to a different calculation method of the CAC score, with the ROI being equal for the two software programs. Our results demonstrated that off-line analysis performed with freeware software may allow a comprehensive evaluation of the oncological patient, making available the evaluation of parameters, such as muscle mass and calcium score, that may be relevant for the staging and prognostic stratification of these patients, beside standard data obtained by PET/CT imaging. For this purpose, the Horos and LIFEx software seem to be interchangeable.