Pretreatment Circulating Vascular Biomarkers Predict Cancer Therapy–Related Cardiac Dysfunction During HER2+ Breast Cancer Treatment

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  Figure 1. Circulating Cardiac Biomarkers Do Not Distinguish Patients Who Developed CTRCD (A) Study schema showing timing of cardiac imaging and biospecimen collection in the EMBRACE-MRI (Evaluation of Myocardial Changes During Breast Adenocarcinoma Therapy to Detect Cardiotoxicity Earlier With MRI) discovery cohort (n = 136). (B) Longitudinal changes in left ventricular ejection fraction (LVEF), as assessed using cardiac magnetic resonance imaging (CMR). Thirty-seven patients developed cancer therapy–related cardiac dysfunction (CTRCD) during the study period on the basis of CMR-defined criteria established by the Cardiac Review and Evaluation Committee, while 99 patients remained free of dysfunction. Values are presented as geometric means with 95% CIs. (C) Circulating cardiac biomarkers were quantified at baseline and early-treatment time points (TP2 and TP3). High-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) were measured in the full cohort (n = 37 CTRCD, n = 99 no-CTRCD), while growth differentiation factor-15 (GDF-15) was measured in a subset of patients (n = 27 per group). Violin plots display the median (Q1-Q3). Asterisks below the x-axis indicate…

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  Figure 2. Circulating Inflammatory and Endothelial Activation Biomarkers Distinguish Patients Who Developed CTRCD (A) The circulating inflammatory biomarkers myeloperoxidase (MPO), interferon-α, interferon γ–induced protein-10 (IP-10), and interleukin-1β (IL-1β) were measured at baseline and during early treatment (TP2 and TP3) in the discovery cohort. MPO was assessed in a subset of patients (n = 27 CTRCD, n = 27 no-CTRCD), while interferon-α, IP-10, and IL-1β were measured in a broader group (n = 25 CTRCD, n = 54 no-CTRCD). Additional inflammatory markers are presented in Supplemental Figure I, with multiple testing correction results detailed in Supplemental Table VII. (B) The endothelial activation markers angiopoietin-2 (ANGPT2), soluble CD62 antigen-like family member E (sE-selectin), endothelin-1 (ET-1), and soluble CD105/endoglin (ENG) were evaluated at the same TPs in a larger subset (n = 37 CTRCD, n = 70 no-CTRCD). Violin plots represent the median (Q1-Q3). Asterisks below the x-axis denote significant intracohort changes from baseline, while asterisks above the plots indicate significant differences between the CTRCD and no-CTRCD groups at each TP. Statistical comparisons were…

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  Figure 3. Analysis of Pretreatment Levels of Inflammatory and Endothelial Activation Biomarkers Distinguishes Those at Risk for CTRCD (A) Baseline concentrations of ANGPT2, sE-selectin, ENG, ET-1, MPO, GDF-15, hs-cTnI, and BNP were measured in all patients in the discovery cohort (n = 37 CTRCD, n = 99 no-CTRCD). The violin plot indicates median (Q1-Q3). ∗P < 0.05, ∗∗P < 0.01, and ∗∗∗P < 0.001 (unpaired Mann-Whitney U test). (B) Baseline concentrations of ANGPT2, MPO, and ENG plotted as a function of the change in CMR LVEF during cancer treatment. Simple linear regression with Spearman correlation coefficients is shown. Abbreviations as in Figures 1 and 2.

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  Figure 4. Plasma miRNAs Are Differentially Abundant at Baseline in Patients Who Developed CTRCD Volcano plot showing differentially expressed plasma microRNAs (miRNAs) in the entire discovery cohort (n = 136) at baseline in patients who developed cancer therapy–related cardiac dysfunction (CTRCD) compared with those who did not. The x-axis indicates log2 fold change, and the y-axis represents −log10(Q value). Dashed lines denote a ±1.5-fold change threshold. MiRNAs with Q values <0.05 are shown in red (up-regulated) or blue (down-regulated); selected miRNAs are labeled. Right panels show Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis of predicted messenger RNA targets of differentially expressed miRNAs. Pathways enriched among up-regulated miRNAs (in CTRCD) are shown in red; those enriched among down-regulated miRNAs are shown in blue. Enrichment scores are presented as −log10(Q value). miR = microRNA; TCA = tricarboxylic acid; TGF = transforming growth factor.

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  Figure 5. Machine Learning Identifies Features That Predict CTRCD Risk From Baseline Data (A) Receiver-operating characteristic curves with areas under the curves and 95% CIs for leave-one-out cross-validation of random forest models trained on baseline data from the discovery cohort (n = 136; 37 with CTRCD defined by the Cardiac Review and Evaluation Committee [CREC] using CMR). Models incorporating clinical, CMR, protein, and miRNA features are shown alone or in combination. Protein biomarkers are sE-selectin, ANGPT2, ENG, ET-1, GDF-15, and MPO. Shown are the specificities and areas under the curves with 95% CIs obtained via bootstrapping. The specificity of each model was assessed at the model threshold that achieved ≥90% sensitivity. (B) Shapley additive explanations (SHAP) value summary plot illustrating the relative contribution of individual variables to model predictions. Feature types are color coded as follows: protein (red), CMR (blue), miRNA (orange), and clinical (green). SHAP value contributions are also color mapped, with red indicating higher feature values and blue indicating lower values. (C) Sensitivity analysis using the European Society of Cardiology (ESC)…

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  Central Illustration. Pretreatment Vascular Signatures in Breast Cancer Patients Elucidate Predispositions to CTRCD Clinical parameters, cardiac imaging, and circulating biomarkers (protein and miRNA) were measured in 136 HER2+ breast cancer patients in the discovery cohort before cancer therapy (anthracyclines and trastuzumab). Features at baseline that distinguished cancer therapy–related cardiac dysfunction (CTRCD) from no-CTRCD patients are indicated. All available baseline data were used to develop a random forest machine learning model to predict CTRCD. Myeloperoxidase (MPO), angiopoietin-2 ANGPT2, and soluble CD105/endoglin (ENG) levels at baseline were found to contribute most to model performance, which was validated in an additional validation cohort of 38 HER2+ breast cancer patients. CTRCD incidence and the area under the receiver-operating characteristic curve (AUC; with 95% CI) are shown. αINF = interferon-α; CMR = cardiac magnetic resonance imaging; CREC = Cardiac Review and Evaluation Committee; EMBRACE-2 = Evaluation of Myocardial Changes During Breast Adenocarcinoma Therapy to Detect Cardiotoxicity Earlier With MRI - 2; EMBRACE MRI = Evaluation of Myocardial Changes During Breast…