Clinical Characteristics Of Hypertension Induced By VEGF Pathway Inhibitors And Its Related Mechanism

Part 1 Relationship Between Drug-induced Hypertension and Prognosis of Tumor Patients Treated with Apatinib Background and Objectives Drug-induced hypertension related to vascular endothelial growth factors(VEGF)inhibitors is one of its most important cardiotoxicity.However,different studies have not yet reached a consistent conclusion on whether hypertension could be a biological marker for efficacy of anti-VEGF therapy.The current study was therefore designed to discuss the epidemiological relationship between hypertension and cancer,and to investigate the incidence of apatinib-induced hypertension,an small molecular tyrosine kinase inhibitor(TKI)targeting VEGF,in the treatment of patients with solid tumor in real world and its associated factors.Furthermore,to determine whether apatinibinduced hypertension is associated with prognosis of patients.Methods We collected the medical records of patients with solid tumor treated with apatinib in Lanzhou University Second Hospital,Gansu Provincial Cancer Hospital and The First People's Hospital of Lazhou City,from Jan 1st 2014 to Jun 31 st 2021 to June 31 st 2021.Patients aged between 18 85 years old with solid tumors and treated with at least one cycle(4 weeks)of apatinib administration were enrolled,either with or without surgery.The participants were then divided into hypertension group and non-hypertension group.The apatinib-induced hypertension was diagnosed using the CTCAE 5.0,which mainly included: i)blood pressure CTCAE 5.0 standard grade 2 or above or started with antihypertensive drug treatment within 1 month to 1 year after the application of apatinib in normotensive patients;ii)systolic blood pressure(SBP)elevation > 20 mm Hg or diastolic blood pressure(DBP)elevation > 10 mm Hg,or increase in the dosage or type of the original antihypertensive therapy in well-controlled hypertensive patients.The patients were then followed to determine the time of disease progression anddeath,as well as whether or not have newly initiated hypertension,proteinuria,handfoot syndrome and other adverse reactions.The deadline for follow-up time was Dec 31 st 2021.The primary outcome of this study was OS,defined as the time from the initiation of apatinib-containing chemotherapy to the death or the follow-up,expressed in months.The secondary outcome was PFS,defined as the time from the initiation of apatinib-containing chemotherapy to the disease progression or the follow-up,expressed in months.The study was approved by the ethics committee of the institution.All statistical analyses were performed with Stata 14.2(Stata Corp LP,USA)and p < 0.05 was considered as statistically different.Results A total of 769 patients were finally included and tumors included were non-small cell lung cancer(NSCLC,n = 59),progressive hepatocellular carcinoma(HCC,n = 85),metastatic colorectal cancer(CRC,n = 206)and GC(n = 419).In all patients,the incidence of apatinib-induced hypertension was 33.3%,and only the history of prehypertension was significantly associated with the occurrence of apatinib-induced hypertension.During the follow-up,a total of 627(81.5%)participants died,with a median OS of 12(8,20)months,of which 185(72.3%)in the hypertension group with a median OS of 20(12,27)months,and 442(86.2%)in the non-hypertension group with the median OS of 10(7,13)months.There were statistically significant differences between the two groups(HR 0.40,95%CI [0.37-0.48],p < 0.0001).The correlation remained significant after adjustment for related factors.Subgroup analyses according to tumor types also revealed significantly correlation between hypertension and longer OS(all p < 0.01).A total of 625(81.3%)had disease progression with a median PFS of 9(5,17)months,of which 182(71.1%)in the hypertension group with a median PFS of 16(10,24)months,and 443(86.4%)in the non-hypertension group with a median PFS of 7(4,11)months.There was a statistically significant difference between the two groups(HR 0.41,95%CI [0.35-0.49],p < 0.001),and it remained significant after adjustment for related factors.Subgroup analyses showed that hypertension was significantly associated with longer PFS in all groups(all p < 0.05)except NSCLC(p = 0.061).Conclusion Hypertension is one of the most adverse effects of apatinib in the treatment of solid tumors,with an incidence of as high as 33.3%.Apatinib-induced hypertension issignificantly correlated with longer OS and PFS,indicating it may be a predictive biomarker of anti-tumor efficacy.Therefore,exploring the underlying mechanism of hypertension induced by VEGF inhibitors,thereby developing more specific antihypertensive drugs,is of vital significance for reducing the interruption of antitumor therapy and improving the prognosis of patients.Part 2 RhoKinase Inhibition Ameliorates Vascular Remodeling and Renal Injury in Apatinib-induced Hypertensive Rat Model Background and Objectives Hypertension induced by TKIs with anti-VEGF activity not only causes discontinuation of anti-tumor therapy,but also exacerbates occurrence of cardiovascular events.To date,little is known regarding the mechanism underlying TKIs-induced hypertension.Recent research evidences have shown that RhoA/Rhokinase(ROCK)signaling pathway in the vasculature is a potential target for therapeutic intervention of salt-sensitive hypertension.On the other hand,sunitinib-induced hypertension has a similar mechanism with salt-sensitive hypertension and could be aggravated by high-salt intake.Therefore,this study aimed to explore the role of the RhoA/ROCK signaling pathway in the elevation of blood pressure induced by apatinib.The non-specific ROCK inhibitor Y27632 was then combined with apatinib to determine its effects on increased blood pressure induced by apatinib.Methods A total of 40 female Wistar–Kyoto rats,were randomly divided into five groups(n = 8 in each group)after one day of adaptive feeding.High(30 mg/kg·d diluted in 2 m L of 0.9% saline solution)or low(15 mg/kg·d diluted in 28) of 0.9% saline solution)dosage of apatinib were administered to the first two groups via oral gavage,whereas Y27632(10 mg/kg·d)was administered to the following two groups via intraperitoneal injection on top of apatinb.Rats in the last group received 2 m L of 0.9% saline solution per day via oral gavage.All the treatments lasted for 15 days.A tail-cuff plethysmography system(IITC Life Science)was used to measure systolic blood pressure(SBP),diastolic blood pressure(DBP),mean blood pressure(MBP)of conscious rats before(baseline)and throughout the treatment period(after every 3 days).The level of creatinine and urine protein,as well as plasma ET-1was determined with biochemical measurements.The m RNA and protein levels in RhoA/ROCK signaling pathway was determined with quantitative real-time polymerase chain reaction(q RTPCR)and western blot analysis,as well as m RNA and proteins related to vascular contraction and remodeling.Finally,the in situ expression of renal tissue fibrosisrelated proteins was detected by immunofluorescence and histological changes were determined with histological analysis.Statistical analyses were performed using SPSS version 25(IBM)and Graph Pad Prism version 6.0(La Jolla,CA).Data followed by p < 0.05 were considered statistically significant.Results Apatinib treatment significantly increased BP from the 3rd 6th day,regardless of whether it was SBP,DBP or MBP,reaching a plateau after 12 days.Compared with low-dose apatinib,high-dose apatinib has a more obvious effect on increasing blood pressure.At the end of intervention,the mean MBP was 111.9 ± 3.6 mm Hg in highdose group and 108.1 ± 1.8 mm Hg(p < 0.001)in low-dose group.Notably,Y27632 significantly abolished the apatinib-induced elevation in BP by 64.6%(p < 0.001)in the high dose(??MBP,17.3 ± 3.0 mm Hg)and by 69.6%(p < 0.001)in the low dose group(??MBP,15.5 ± 2.1 mm Hg).The m RNA and protein levels of RhoA and ROCK ? in mid-aorta increased at different apatinib doses(both p < 0.001 vs.vehicle),more significant in the high dose group,while the m RNA level of GRAF3 decreased(p < 0.001 vs.vehicle).However,apatinib caused no significant change in m RNA and protein level of ROCK ?.Apatinib administration downregulated protein levels of myosin light chain phosphatase(MLCP)and m RNA levels of e NOS in the mid-aorta,while upregulated protein levels of ETA and Col ? in the mid-aorta,as well as circulating ET-1 level.Furthermore,the number of glomerular capillaries marked by CD31 in renal cortex decreased while epithelial–mesenchymal transition(EMT)marked by ?-SMA in renal interstitium increased with administration of apatinib,especially at the dosage of 30 mg/kg·d,which were also reversed by Y27632.However,all the changes were reversed by Y27632 administration.Proteinuria increased with administration of high dose apatinib(30 mg/kg·d),while reversed by Y27632(p < 0.001).Conclusion Results of the present study indicated that apatinib treatment increased blood pressure,accompanied by activation of the RhoA/ROCK signaling pathway and increasedexpression of vasoconstriction-related proteins,vascular proliferation,and renal injury.However,Y27632,a non-specific ROCK inhibitor,reversed apatinib-induced injury,suggesting that the activation of the RhoA/ROCK signaling pathway could be the underlying mechanism of apatinib-induced hypertension,while ROCK inhibitors could be potential therapeutic drugs.Part 3 The Predictive Value of Drug-induced Hypertension on Long-term Prognosis of Tumor Patients Treated with Tyrosine Kinase Inhibitors Background and Objectives Hypertension is one of the most common adverse events of small molecular TKIs targeting VEGF.In the first part of this study,we found that the incidence of apatinibinduced hypertension in the real world was 33.3%,and it was significantly correlated with OS and PFS of patients with solid tumors.Therefore,the current study was designed to evaluate whether apatinib-induced hypertension is related to its anti-tumor efficacy and the long-term prognosis of patients during the treatment of solid tumors with small molecule TKI of the VEGF pathway.Furthermore,to explore the effects of antihypertensive drugs on tumor and the effects of antitumor drugs on blood pressure.Finally,to summarize the antihypertensive treatment strategies for cancer patients with hypertension.Methods We conducted a systematic review with a meta-analysis using Cochrane Collaboration methodology and PRISMA and GRADE guidelines.Researches from 1980 to August 31,2021 were included if they evaluated the correlation between drug-induced hypertension and prognosis of patients treated with TKIs,with at least one of the following indicators: objective response rate(ORR),PFS or OS.We included all publications of observational,retrospective or prospective randomized controlled studies.Quality of publication was evaluated with the Newcastle-Ottawascale(NOS)scale.The primary outcome of this study was OS,while the secondary outcomes were PFS and ORR,which was defined as the proportion of patients who have achieved complete response(CR),partial response(PR)or stable disease(SD)after TKIstreatment.For each outcome,overall analysis,as well as subgroup analysis was performed according to the intervention drugs and tumor types.All statistical analyses were performed using Stata 14.2(Stata Corp LP,USA).p < 0.05 was considered as statistically different.Results A total of 58 studies were considered eligible,with 10020 patients included,30 of which were retrospective cohort study(RCS),9 were prospective cohort studies(PCS),and 19 were Post-hoc analysis of RCT(PH-RCT).Intervention drugs were sorafenib,sunitinib,apatinib,anlotinib,axitinib,pazopanib,regorafenib,levatinib and cabozantinib.The included tumor types were metastatic or progressive renal cell carcinoma(RCC),HCC,NSCLC,CRC,gastrointestinal stromal tumor(GST),thyroid carcinoma(TC),breast cancer(BC),esophageal squamous cell carcinoma(ESCC),osteosarcoma(OST),squamous cell lung cancer(Sq CLC),soft tissue sarcoma(STS)and small cell lung cancer(SCLC).The incidence of TKI-induced hypertension was 7.5% 79.7%,with an average of 45.6% ± 17%.In overall analyses,hypertension was significantly correlated with longer OS(HR 0.54,95% CI [0.49-0.61],p < 0.0001),however,there was significant heterogeneity(I2 = 59.4%,p < 0.0001).The results of subgroup analyses by intervention drugs showed that the heterogeneity for apatinib,anlotinib,and sorafenib decreased significantly,and correlation between hypertension and longer OS remained significant in all subgroups(p < 0.05 for all)except for pazopanib(p = 0.055).The results of subgroup analyses by tumor types showed that the heterogeneity in NSCLC and HCC was significantly reduced,and hypertension was significantly associated with longer OS in all subgroups(p < 0.05 for all).TKIs-induced hypertension was significantly correlated with longer PFS(HR 0.55,95% CI [0.48-0.63],p < 0.0001)in overall analyses,but there was significant heterogeneity between studies(I2 = 74.6%,p < 0.0001).The results of subgroup analyses by intervention drugs showed that the heterogeneity for apatinib,anlotinib and pazopanib was significantly reduced,while the heterogeneity for sunitinib,sorafenib and axitinib remained high.Hypertension was significantly correlated with longer PFS in all subgroups(p < 0.05)except in pazopanib group(p = 0.085).The subgroup analyses by tumor types was also performed.Only the NSCLC and TC group reached low heterogeneity,while hypertension in all subgroups were significantly correlated with longer PFS(all p < 0.05).A total of 17 studies provided data on the correlation between hypertension and ORR.Hypertension was significantly correlated with better ORR(p < 0.0001),though with significant heterogeneity between the studies(I2 = 55.0%,p = 0.003).The subgroup analyses by intervention drugs showed that the heterogeneity was significantly reduced,with positive correlation between hypertension and ORR(p < 0.05 for all)except in the apatinib group(p = 0.159).The heterogeneities in HCC and NSCLC groups reduced significantly in subgroup analyses,while heterogeneity in RCC group remained high.However,hypertension was significantly associated with better ORR in all of the subgroup analyses(p < 0.01 for all).Conclusion TKIs-induced hypertension has a significant correlation with tumor efficacy and prognosis of patients,thereby it may be one of the biological markers of TKI treatment.Therefore,it is of vital significance to screening cardiovascular risk factors,monitoring blood pressure and managing hypertension before the initiation and during the treatment of TKIs,rather than interrupting antitumor therapy.