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Kadia TM, Gandhi V. Nelarabine in the treatment of pediatric and adult patients with T-cell acute lymphoblastic leukemia and lymphoma. Expert Rev Hematol 2016; 10:1-8. [PMID: 27869523 DOI: 10.1080/17474086.2017.1262757] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION T-cell acute lymphoblastic leukemia (ALL) and lymphoma (LBL) are aggressive hematologic neoplasms that are treated with combination chemotherapy in the frontline, but have limited options in the relapsed or refractory setting. Based on observations in patients with purine nucleoside phosphorylase (PNP) deficiency, a guanosine nucleoside analogue, arabinosylguanine (ara-G) was developed that provided T-cell specificity. Nelarabine was developed as the water-soluble, clinically useful-prodrug of ara-G and based on its activity was approved for the treatment of relapsed or refractory T-ALL/LBL. Areas covered: In this narrative review, we will summarize the preclinical studies, early dose-finding studies, and efficacy studies that led to approval of nelarabine. The review will succinctly cover response rates and safety signals reported during clinical development. We will also cover more recent work with nelarabine, including combination studies, modified dosing schedules, and frontline treatment approaches. Expert commentary: Based on evidence from the literature review and our own experience with nelarabine, we conclude that it is an effective agent in the treatment of T-cell malignancies. Understanding the factors that modulate the risk of dose-limiting neurotoxicity, how to mitigate this toxicity, and how to safely combine it with other active agents will continue to broaden its use.
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Affiliation(s)
- Tapan M Kadia
- a Departments of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Varsha Gandhi
- a Departments of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA.,b Departments of Experimental Therapeutics , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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Raetz EA, Teachey DT. T-cell acute lymphoblastic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:580-588. [PMID: 27913532 PMCID: PMC6142501 DOI: 10.1182/asheducation-2016.1.580] [Citation(s) in RCA: 161] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
T-cell acute lymphoblastic leukemia (T-ALL) is biologically distinct from its B lymphoblastic (B-ALL) counterpart and shows different kinetic patterns of disease response. Although very similar regimens are used to treat T-ALL and B-ALL, distinctions in response to different elements of therapy have been observed. Similar to B-ALL, the key prognostic determinant in T-ALL is minimal residual disease (MRD) response. Unlike B-ALL, other factors including age, white blood cell count at diagnosis, and genetics of the ALL blasts are not independently prognostic when MRD response is included. Recent insights into T-ALL biology, using modern genomic techniques, have identified a number of recurrent lesions that can be grouped into several targetable pathways, including Notch, Jak/Stat, PI3K/Akt/mTOR, and MAPK. With contemporary chemotherapy, outcomes for de novo T-ALL have steadily improved and now approach those observed in B-ALL, with approximately 85% 5-year event-free survival. Unfortunately, salvage has remained poor, with less than 25% event-free and overall survival rates for relapsed disease. Thus, current efforts are focused on preventing relapse by augmenting therapy for high-risk patients, sparing toxicity in favorable subsets and developing new approaches for the treatment of recurrent disease.
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Affiliation(s)
- Elizabeth A. Raetz
- Department of Pediatrics and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - David T. Teachey
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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Lonetti A, Cappellini A, Bertaina A, Locatelli F, Pession A, Buontempo F, Evangelisti C, Evangelisti C, Orsini E, Zambonin L, Neri LM, Martelli AM, Chiarini F. Improving nelarabine efficacy in T cell acute lymphoblastic leukemia by targeting aberrant PI3K/AKT/mTOR signaling pathway. J Hematol Oncol 2016; 9:114. [PMID: 27776559 PMCID: PMC5075755 DOI: 10.1186/s13045-016-0344-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/14/2016] [Indexed: 11/21/2022] Open
Abstract
Background Although in recent years, the introduction of novel chemotherapy protocols has improved the outcome of T cell acute lymphoblastic leukemia (T-ALL) patients, refractory and/or relapsing disease remains a foremost concern. In this context, a major contribution was provided by the introduction of the nucleoside analog nelarabine, approved for salvage treatment of T-ALL patients with refractory/relapsed disease. However, nelarabine could induce a life-threatening, dose-dependent neurotoxicity. To improve nelarabine efficacy, we have analyzed its molecular targets, testing selective inhibitors of such targets in combination with nelarabine. Methods The effectiveness of nelarabine as single agent or in combination with PI3K, Bcl2, and MEK inhibitors was evaluated on human T-ALL cell lines and primary T-ALL refractory/relapsed lymphoblasts. The efficacy of signal modulators in terms of cytotoxicity, induction of apoptosis, and changes in gene and protein expression was assessed by flow cytometry, western blotting, and quantitative real-time PCR in T-ALL settings. Results Treatment with nelarabine as a single agent identified two groups of T-ALL cell lines, one sensitive and one resistant to the drug. Whereas sensitive T-ALL cells showed a significant increase of apoptosis and a strong down-modulation of PI3K signaling, resistant T-ALL cells showed a hyperactivation of AKT and MEK/ERK1/2 signaling pathways, not caused by differences in the expression of nelarabine transporters or metabolic activators. We then studied the combination of nelarabine with the PI3K inhibitors (both pan and dual γ/δ inhibitors), with the Bcl2 specific inhibitor ABT199, and with the MEK inhibitor trametinib on both T-ALL cell lines and patient samples at relapse, which displayed constitutive activation of PI3K signaling and resistance to nelarabine alone. The combination with the pan PI3K inhibitor ZSTK-474 was the most effective in inhibiting the growth of T-ALL cells and was synergistic in decreasing cell survival and inducing apoptosis in nelarabine-resistant T-ALL cells. The drug combination caused AKT dephosphorylation and a downregulation of Bcl2, while nelarabine alone induced an increase in p-AKT and Bcl2 signaling in the resistant T-ALL cells and relapsed patient samples. Conclusions These findings indicate that nelarabine in combination with PI3K inhibitors may be a promising therapeutic strategy for the treatment of T-ALL relapsed patients. Electronic supplementary material The online version of this article (doi:10.1186/s13045-016-0344-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annalisa Lonetti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Alessandra Cappellini
- Department of Human Social and Health Sciences, University of Cassino, Cassino, Italy
| | - Alice Bertaina
- Department of Pediatric Hematology-Oncology, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology-Oncology, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Pession
- Department of Pediatrics, "Lalla Seràgnoli" Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Francesca Buontempo
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Camilla Evangelisti
- Institute of Molecular Genetics, Rizzoli Orthopedic Institute, National Research Council, Bologna, Italy
| | - Cecilia Evangelisti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Ester Orsini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Laura Zambonin
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Luca Maria Neri
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Alberto Maria Martelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
| | - Francesca Chiarini
- Institute of Molecular Genetics, Rizzoli Orthopedic Institute, National Research Council, Bologna, Italy.
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Long-term outcome of 6-month maintenance chemotherapy for acute lymphoblastic leukemia in children. Leukemia 2016; 31:580-584. [PMID: 27698447 DOI: 10.1038/leu.2016.274] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 07/29/2016] [Accepted: 09/06/2016] [Indexed: 12/27/2022]
Abstract
In the treatment of childhood acute lymphoblastic leukemia (ALL), excess shortening of maintenance therapy resulted in high relapse rate, as shown by our previous trial, TCCSG L92-13, in which maintenance therapy was terminated at 1 year from initiation of treatment. In this study, we aimed to confirm the long-term outcome of L92-13, and to identify who can or cannot be cured by shorter duration of maintenance therapy. To obtain sentinel cytogenetics information that had been missed before, we performed genetic analysis with genomic microarray and target intron-capture sequencing from diagnostic bone marrow smear. Disease-free survival (DFS) at 10 years from the end of therapy was 66.0±2.8%. Females (n=138) had better DFS (74.6±3.7%) than males (n=142, 57.5±4.2%, P=0.002). Patients with TCF3-PBX1 (n=11) and ETV6-RUNX1 (n=16) had excellent DFS (90.9±8.7% and 93.8±6.1%, respectively), whereas high hyperdiploidy (n=23) was the most unfavorable subgroup, with 56.6±10.3% of DFS. Short duration of therapy can cure more than half of pediatric ALL, especially females, TCF3-PBX1 and ETV6-RUNX1. Our retrospective observations suggest a gender/karyotype inhomogeneity on the impact of brief therapy.
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Huo JS, Symons HJ, Robey N, Borowitz M, Schafer ES, Chen AR. Persistent Multiyear Control of Relapsed T-Cell Acute Lymphoblastic Leukemia With Successive Donor Lymphocyte Infusions: A Case Report. Pediatr Blood Cancer 2016; 63:1279-82. [PMID: 26990138 PMCID: PMC4877254 DOI: 10.1002/pbc.25971] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/18/2016] [Accepted: 02/18/2016] [Indexed: 12/14/2022]
Abstract
There are few therapeutic options for patients with T-cell acute lymphoblastic leukemia (T-ALL) who have recurrent disease after initial matched sibling hematopoietic stem cell transplantation. While a second hematopoietic stem cell transplant (HSCT) from a haploidentical donor offers the conceptual possibility of greater graft versus leukemia effect, there is minimal literature to describe the efficacy of this approach in recurrent pediatric T-ALL. We present the case of a now 9-year-old female in whom second haploidentical HSCT, followed by successive donor lymphocyte infusions in response to minimal residual disease reemergence, has led to 3+ years of ongoing disease control without graft versus host disease and excellent quality of life.
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Affiliation(s)
- Jeffrey S Huo
- Division of Pediatric Oncology, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heather J Symons
- Division of Pediatric Oncology, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nancy Robey
- Division of Pediatric Oncology, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Borowitz
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore MD, USA
| | - Eric S Schafer
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Allen R Chen
- Division of Pediatric Oncology, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sorge CE, McDaniel JK, Xavier AC. Targeted Therapies for the Treatment of Pediatric Non-Hodgkin Lymphomas: Present and Future. Pharmaceuticals (Basel) 2016; 9:E28. [PMID: 27213405 PMCID: PMC4932546 DOI: 10.3390/ph9020028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/03/2016] [Accepted: 05/12/2016] [Indexed: 01/24/2023] Open
Abstract
Pediatric Non-Hodgkin Lymphomas (NHL) are a diverse group of malignancies and as such treatment can vary based on the different biological characteristics of each malignancy. Significant advancements are being made in the treatment and outcomes of this group of malignancies. This is in large part due to novel targeted drug therapies that are being used in combination with traditional chemotherapy. Here, we discuss several new lines of therapy that are being developed or are in current use for pediatric patients with NHL.
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Affiliation(s)
- Caryn E Sorge
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
| | - Jenny K McDaniel
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
| | - Ana C Xavier
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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Badke C, Fleming A, Iqbal A, Khilji O, Parhas S, Weinstein J, Morgan E, Hijiya N. Rechallenging With Intrathecal Methotrexate After Developing Subacute Neurotoxicity in Children With Hematologic Malignancies. Pediatr Blood Cancer 2016; 63:723-6. [PMID: 26681571 DOI: 10.1002/pbc.25850] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 10/27/2015] [Indexed: 11/06/2022]
Abstract
Methotrexate is associated with neurologic side effects. It is recommended that patients who developed neurotoxicity be rechallenged with methotrexate, but little is known about the safety of this approach. We performed a chart review to identify patients who received high-dose or intrathecal (IT) methotrexate. Twenty-one of 298 patients (7%) experienced neurologic symptoms attributed to methotrexate treatment in the premaintenance phase. Seventeen of these patients were rechallenged with IT methotrexate and 13 (76%) had no further neurotoxic events. No patients rechallenged during maintenance (n = 9) experienced recurrence of neurotoxic events. It is safe to rechallenge with IT methotrexate in maintenance.
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Affiliation(s)
- Colleen Badke
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amy Fleming
- Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Asneha Iqbal
- Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ohmed Khilji
- Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Sophia Parhas
- Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Joanna Weinstein
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Elaine Morgan
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Nobuko Hijiya
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Burkhardt B, Mueller S, Khanam T, Perkins SL. Current status and future directions of T-lymphoblastic lymphoma in children and adolescents. Br J Haematol 2016; 173:545-59. [DOI: 10.1111/bjh.14017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Birgit Burkhardt
- Paediatric Haematology and Oncology; University Hospital Muenster; Germany
| | - Stephanie Mueller
- Paediatric Haematology and Oncology; University Hospital Muenster; Germany
| | - Tasneem Khanam
- Paediatric Haematology and Oncology; University Hospital Muenster; Germany
| | - Sherrie L. Perkins
- Department of Pathology; University of Utah Health Sciences Center, ARUP Institute for Clinical and Experimental Pathology; Salt Lake City Utah
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CD44 promotes chemoresistance in T-ALL by increased drug efflux. Exp Hematol 2016; 44:166-71.e17. [DOI: 10.1016/j.exphem.2015.12.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/28/2015] [Accepted: 12/01/2015] [Indexed: 11/20/2022]
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60
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Bassan R, Maino E, Cortelazzo S. Lymphoblastic lymphoma: an updated review on biology, diagnosis, and treatment. Eur J Haematol 2016; 96:447-60. [DOI: 10.1111/ejh.12722] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 12/21/2022]
Affiliation(s)
- Renato Bassan
- Unità Operativa Complessa di Ematologia; Ospedale dell'Angelo & Ospedale SS. Giovanni e Paolo; Mestre-Venezia Italy
| | - Elena Maino
- Unità Operativa Complessa di Ematologia; Ospedale dell'Angelo & Ospedale SS. Giovanni e Paolo; Mestre-Venezia Italy
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Tasian SK, Loh ML, Hunger SP. Childhood acute lymphoblastic leukemia: Integrating genomics into therapy. Cancer 2015; 121:3577-90. [PMID: 26194091 PMCID: PMC4592406 DOI: 10.1002/cncr.29573] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 05/31/2015] [Accepted: 06/17/2015] [Indexed: 12/31/2022]
Abstract
Acute lymphoblastic leukemia (ALL), the most common malignancy of childhood, is a genetically complex entity that remains a major cause of childhood cancer-related mortality. Major advances in genomic and epigenomic profiling during the past decade have appreciably enhanced knowledge of the biology of de novo and relapsed ALL and have facilitated more precise risk stratification of patients. These achievements have also provided critical insights regarding potentially targetable lesions for the development of new therapeutic approaches in the era of precision medicine. In this review, the authors delineate the current genetic landscape of childhood ALL, emphasizing patient outcomes with contemporary treatment regimens as well as therapeutic implications of newly identified genomic alterations in specific subsets of ALL.
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Affiliation(s)
- Sarah K Tasian
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia; Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Abramson Cancer Center; Philadelphia, PA
| | - Mignon L Loh
- University of California, San Francisco Benioff Children's Hospital; San Francisco, CA
- Helen Diller Family Comprehensive Cancer Center; San Francisco, CA
| | - Stephen P Hunger
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia; Philadelphia, PA
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Abstract
Adolescent and young adult (AYA) patients with cancer are a unique category of patients who, depending on age at time of diagnosis, might receive treatment from oncologists specializing either in the treatment of children or adults. In the USA, AYA oncology generally encompasses patients 15-39 years of age. AYA patients with cancer typically present with diseases that span the spectrum from 'paediatric' cancers (such as acute lymphoblastic leukaemia [ALL] and brain tumours) to 'adult' tumours (such as breast cancer and melanoma), as well as cancers that are largely unique to their age group (such as testicular cancer and bone tumours). Research indicates that outcomes of AYA patients with cancer are influenced not only by the treatment provided, but also by factors related to 'host' biology. In addition to the potential biological and cancer-specific differences between AYAs and other patients with cancer, AYA patients also often have disparate access to clinical trials and suffer from a lack of age-appropriate psychosocial support services and health services, which might influence survival as well as overall quality of life. In this Review, these issues are discussed, with a focus on two types of AYA cancer--ALL and melanoma--highlighting findings arising from the use of emerging technologies, such as whole-genome sequencing.
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