1
|
Delombaerde D, De Sutter J, Croes L, Vervloet D, Moerman V, Van de Veire N, Willems AM, Wouters K, Peeters M, Prenen H, Vulsteke C. Extensive CArdioVAscular Characterization and Follow-Up of Patients Receiving Immune Checkpoint Inhibitors: A Prospective Multicenter Study. Pharmaceuticals (Basel) 2023; 16:ph16040625. [PMID: 37111382 PMCID: PMC10142365 DOI: 10.3390/ph16040625] [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: 03/21/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The increasing use of immune checkpoint inhibitors (ICIs) in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in the incidence of cardiovascular (CV) immune-related adverse events (irAEs). The current follow-up guidelines are based on anecdotal evidence and expert opinions, due to a lack of solid data and prospective studies. As many questions remain unanswered, cardiac monitoring, in patients receiving ICIs, is not always implemented by oncologists. Hence, an urgent need to investigate the possible short- and long-term CV effects of ICIs, as ICI approval is continuing to expand to the (neo)adjuvant setting. METHODS We have initiated a prospective, multicenter study, i.e., the CAVACI trial, in which a minimum of 276 patients with a solid tumor, eligible for ICI treatment, will be enrolled. The study consists of routine investigations of blood parameters (troponin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, in particular) and a thorough CV follow-up (electrocardiograms, transthoracic echocardiograms, and coronary calcium scoring) at fixed time points for a total period of two years. The primary endpoint is the cumulative incidence of troponin elevation in the first three months of ICI treatment, compared to baseline levels. Furthermore, secondary endpoints include incidence above the upper limit of normal of both troponin and NT-proBNP levels, evolution in troponin and NT-proBNP levels, the incidence of CV abnormalities/major adverse cardiac events, evaluation of associations between patient characteristics/biochemical parameters and CV events, transthoracic echocardiography parameters, electrocardiography parameters, and progression of coronary atherosclerosis. Recruitment of patients started in January 2022. Enrolment is ongoing in AZ Maria Middelares, Antwerp University Hospital, AZ Sint-Vincentius Deinze, and AZ Sint-Elisabeth Zottegem. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05699915, registered 26 January 2023.
Collapse
Affiliation(s)
- Danielle Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | - Johan De Sutter
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | - Lieselot Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | | | | | - Nico Van de Veire
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Department of Cardiology, Free University Brussels, 1000 Brussels, Belgium
| | | | - Kristien Wouters
- Antwerp University Hospital, Clinical Trial Center (CTC), CRC Antwerp, 2650 Edegem, Belgium
| | - Marc Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Hans Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Christof Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| |
Collapse
|
2
|
Verhé M, De Somer T, Defoort B, Vanderstraeten E, Monsaert E, Bouderez V, Dias S, Delombaerde D, Vulsteke C, Van Steenkiste C. The Role of Abdominal Surgery in Refractory Immune Checkpoint Inhibitor Enterocolitis: A Case Report. Case Rep Oncol 2023; 16:438-445. [PMID: 37384210 PMCID: PMC10294263 DOI: 10.1159/000530832] [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: 11/03/2022] [Accepted: 04/18/2023] [Indexed: 06/30/2023] Open
Abstract
This article describes the case of a 73-year-old patient with grade 3 immune checkpoint inhibitor (ICI)-induced enteritis. Five different immunosuppressive agents (glucocorticoids, high-dose infliximab, methotrexate, mycophenolate mofetil, and vedolizumab) were administered, however, with no clinical or radiographical benefit. A laparotomy was performed, as the patient showed signs of intestinal obstruction, with a segmental resection of the ileal loop. Biopsy results showed multiple fibrotic strictures. The current treatment guidelines for ICI enterocolitis only include drugs as a treatment option. Nevertheless, it remains important to consider early surgical intervention in order to avoid serious complications due to persistent and pronounced inflammation. The current case highlights the importance of surgery as a treatment modality in the multidisciplinary approach for ICI-induced enteritis, which should be taken into consideration after second- or third-line treatment.
Collapse
Affiliation(s)
- Manon Verhé
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
| | - Thomas De Somer
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
| | | | - Erik Vanderstraeten
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - Els Monsaert
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - Vincent Bouderez
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - Stefanie Dias
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - Danielle Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Ghent, Belgium
| | - Christof 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
| | - Christophe Van Steenkiste
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
- 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
- Department of Gastroenterology, University of Antwerp, Edegem, Belgium
| |
Collapse
|
3
|
Delombaerde D, Vervloet D, Berwouts D, Beckers R, Prenen H, Peeters M, Gremonprez F, Croes L, Vulsteke C. Ipilimumab- and nivolumab-induced myocarditis in a patient with metastatic cholangiocarcinoma: a case report. J Med Case Rep 2022; 16:275. [PMID: 35831829 PMCID: PMC9281161 DOI: 10.1186/s13256-022-03487-4] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/10/2022] [Indexed: 01/08/2023] Open
Abstract
Background Myocarditis in patients treated with immune checkpoint inhibitors has previously been reported to be rare, though it has most likely been underreported owing to misdiagnosis in the absence of overt clinical presentation. Early detection and characterization of this potentially life-threatening immune-related adverse event is of major importance. Herein we report a case of early-onset myocarditis in an asymptomatic patient treated with dual checkpoint inhibition for metastatic cholangiocarcinoma. Case presentation A 69-year-old male Caucasian patient with metastatic cholangiocarcinoma presented with mild epigastric pain and troponinemia prior to the third dose of dual checkpoint inhibition (ipilimumab 1 mg/kg body weight and nivolumab 3 mg/kg body weight). Initial workup showed no significant abnormalities (physical/neurological examination, electrocardiogram, 72-hour Holter monitoring, and a transthoracic echocardiogram). However, cardiac magnetic resonance imaging revealed a zone of contrast enhancement in the inferior segment of the left ventricular wall indicating a recent episode of myocarditis. Despite steroid initiation (0.5 mg/kg oral prednisolone per day), troponin levels kept increasing, in the absence of coronary disease, for which steroids were increased to 1.5 mg/kg/day. Fluorodeoxyglucose positron emission tomography/computed tomography, 28 days after detecting elevated troponin levels, depicted multiple zones of active myocardial inflammation (basal septal, mid-anterior, and apical inferior). The patient is currently stable, and troponinemia is slowly decreasing while steroids are steadily being tapered. Conclusion As the number of cancers treated with immune checkpoint inhibitors is expanding, the incidence of immune checkpoint inhibitor-induced myocarditis is likely to increase. Moreover, the emerging combination of immune checkpoint inhibitors with non-immune checkpoint inhibitor therapies with potential synergistic cardiotoxic side effects (for example, tyrosine kinase inhibitors) will further complicate the diagnosis of immune-related cardiotoxicity. This case highlights the urgent need for predictive biomarkers to stratify patients at risk and to develop a standardized and multidisciplinary management approach for early diagnosis and treatment of this severe immune-related adverse event.
Collapse
Affiliation(s)
- Danielle Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Buitenring Sint-Denijs 30, 9000, Ghent, Belgium. .,Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium.
| | - Delphine Vervloet
- Department of Cardiology, AZ Maria Middelares, Buitenring Sint-Denijs 30, 9000, Ghent, Belgium
| | - Dieter Berwouts
- Department of Nuclear Medicine, AZ Maria Middelares, Buitenring Sint-Denijs 30, 9000, Ghent, Belgium
| | - Roel Beckers
- Department of Radiology, AZ Maria Middelares, Buitenring Sint-Denijs 30, 9000, Ghent, Belgium
| | - Hans Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium.,Multidisciplinary Oncologic Centre Antwerp (MOCA), Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Marc Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium.,Multidisciplinary Oncologic Centre Antwerp (MOCA), Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Félix Gremonprez
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Buitenring Sint-Denijs 30, 9000, Ghent, Belgium
| | - Lieselot Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Buitenring Sint-Denijs 30, 9000, Ghent, Belgium.,Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Christof Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, Buitenring Sint-Denijs 30, 9000, Ghent, Belgium.,Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| |
Collapse
|
4
|
Velasco-Ruiz A, Nuñez-Torres R, Pita G, Wildiers H, Lambrechts D, Hatse S, Delombaerde D, Van Brussel T, Alonso MR, Alvarez N, Herraez B, Vulsteke C, Zamora P, Lopez-Fernandez T, Gonzalez-Neira A. POLRMT as a Novel Susceptibility Gene for Cardiotoxicity in Epirubicin Treatment of Breast Cancer Patients. Pharmaceutics 2021; 13:1942. [PMID: 34834357 PMCID: PMC8622627 DOI: 10.3390/pharmaceutics13111942] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/06/2021] [Accepted: 11/12/2021] [Indexed: 11/27/2022] Open
Abstract
Anthracyclines are among the most used chemotherapeutic agents in breast cancer (BC). However their use is hampered by anthracycline-induced cardiotoxicity (AIC). The currently known clinical and genetic risk factors do not fully explain the observed inter-individual variability and only have a limited ability to predict which patients are more likely to develop this severe toxicity. To identify novel predictive genes, we conducted a two-stage genome-wide association study in epirubicin-treated BC patients. In the discovery phase, we genotyped over 700,000 single nucleotide variants in a cohort of 227 patients. The most interesting finding was rs62134260, located 4kb upstream of POLRMT (OR = 5.76, P = 2.23 × 10-5). We replicated this association in a validation cohort of 123 patients (P = 0.021). This variant regulates the expression of POLRMT, a gene that encodes a mitochondrial DNA-directed RNA polymerase, responsible for mitochondrial gene expression. Individuals harbouring the risk allele had a decreased expression of POLRMT in heart tissue that may cause an impaired capacity to maintain a healthy mitochondrial population in cardiomyocytes under stressful conditions, as is treatment with epirubicin. This finding suggests a novel molecular mechanism involved in the development of AIC and may improve our ability to predict patients who are at risk.
Collapse
Affiliation(s)
- Alejandro Velasco-Ruiz
- Human Genotyping Unit, CeGen (Spanish National Genotyping Centre), Human Cancer Genetics Programme, Spanish National Cancer Research Centre (CNIO), Calle de Melchor Fernández Alamagro, 3, 28029 Madrid, Spain; (A.V.-R.); (R.N.-T.); (G.P.); (M.R.A.); (N.A.); (B.H.)
| | - Rocio Nuñez-Torres
- Human Genotyping Unit, CeGen (Spanish National Genotyping Centre), Human Cancer Genetics Programme, Spanish National Cancer Research Centre (CNIO), Calle de Melchor Fernández Alamagro, 3, 28029 Madrid, Spain; (A.V.-R.); (R.N.-T.); (G.P.); (M.R.A.); (N.A.); (B.H.)
| | - Guillermo Pita
- Human Genotyping Unit, CeGen (Spanish National Genotyping Centre), Human Cancer Genetics Programme, Spanish National Cancer Research Centre (CNIO), Calle de Melchor Fernández Alamagro, 3, 28029 Madrid, Spain; (A.V.-R.); (R.N.-T.); (G.P.); (M.R.A.); (N.A.); (B.H.)
| | - Hans Wildiers
- Department of General Medical Oncology, University Hospital of Leuven, Herestraat 49, 3000 Leuven, Belgium;
- Multidisciplinary Breast Centre, University Hospital of Leuven, Herestraat 49, 3000 Leuven, Belgium;
- Laboratory of Experimental Oncology (LEO), Department of Oncology, Katholieke Universiteit (KU) Leuven, Oude Markt 13, 3000 Leuven, Belgium
| | - Diether Lambrechts
- Laboratory of Translational Genetics, Centre for Cancer Biology (CCB), Flanders Institute for Biotechnology (VIB), Rijvisschestraat 120, 9052 Leuven, Belgium; (D.L.); (T.V.B.)
| | - Sigrid Hatse
- Multidisciplinary Breast Centre, University Hospital of Leuven, Herestraat 49, 3000 Leuven, Belgium;
- Laboratory of Experimental Oncology (LEO), Department of Oncology, Katholieke Universiteit (KU) Leuven, Oude Markt 13, 3000 Leuven, Belgium
| | - Danielle Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium; (D.D.); (C.V.)
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | - Thomas Van Brussel
- Laboratory of Translational Genetics, Centre for Cancer Biology (CCB), Flanders Institute for Biotechnology (VIB), Rijvisschestraat 120, 9052 Leuven, Belgium; (D.L.); (T.V.B.)
| | - M. Rosario Alonso
- Human Genotyping Unit, CeGen (Spanish National Genotyping Centre), Human Cancer Genetics Programme, Spanish National Cancer Research Centre (CNIO), Calle de Melchor Fernández Alamagro, 3, 28029 Madrid, Spain; (A.V.-R.); (R.N.-T.); (G.P.); (M.R.A.); (N.A.); (B.H.)
| | - Nuria Alvarez
- Human Genotyping Unit, CeGen (Spanish National Genotyping Centre), Human Cancer Genetics Programme, Spanish National Cancer Research Centre (CNIO), Calle de Melchor Fernández Alamagro, 3, 28029 Madrid, Spain; (A.V.-R.); (R.N.-T.); (G.P.); (M.R.A.); (N.A.); (B.H.)
| | - Belen Herraez
- Human Genotyping Unit, CeGen (Spanish National Genotyping Centre), Human Cancer Genetics Programme, Spanish National Cancer Research Centre (CNIO), Calle de Melchor Fernández Alamagro, 3, 28029 Madrid, Spain; (A.V.-R.); (R.N.-T.); (G.P.); (M.R.A.); (N.A.); (B.H.)
| | - Christof Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium; (D.D.); (C.V.)
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | - Pilar Zamora
- Department of Medical Oncology, University Hospital La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain;
| | - Teresa Lopez-Fernandez
- Department of Cardiology, University Hospital La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain;
| | - Anna Gonzalez-Neira
- Human Genotyping Unit, CeGen (Spanish National Genotyping Centre), Human Cancer Genetics Programme, Spanish National Cancer Research Centre (CNIO), Calle de Melchor Fernández Alamagro, 3, 28029 Madrid, Spain; (A.V.-R.); (R.N.-T.); (G.P.); (M.R.A.); (N.A.); (B.H.)
| |
Collapse
|
5
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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
|