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Ma S, La J, Swinnerton KN, Guffey D, Bandyo R, Pozas GDL, Hanzelka K, Xiao X, Hernandez CR, Amos CI, Chitalia V, Ravid K, Merriman KW, Flowers CR, Fillmore NR, Li A. Thrombosis risk prediction in lymphoma patients: A multi-institutional, retrospective model development and validation study. Am J Hematol 2024; 99:1230-1239. [PMID: 38654461 PMCID: PMC11166507 DOI: 10.1002/ajh.27335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/05/2024] [Accepted: 03/23/2024] [Indexed: 04/26/2024]
Abstract
Venous thromboembolism (VTE) poses a significant risk to cancer patients receiving systemic therapy. The generalizability of pan-cancer models to lymphomas is limited. Currently, there are no reliable risk prediction models for thrombosis in patients with lymphoma. Our objective was to create a risk assessment model (RAM) specifically for lymphomas. We performed a retrospective cohort study to develop Fine and Gray sub-distribution hazard model for VTE and pulmonary embolism (PE)/ lower extremity deep vein thrombosis (LE-DVT) respectively in adult lymphoma patients from the Veterans Affairs national healthcare system (VA). External validations were performed at the Harris Health System (HHS) and the MD Anderson Cancer Center (MDACC). Time-dependent c-statistic and calibration curves were used to assess discrimination and fit. There were 10,313 (VA), 854 (HHS), and 1858 (MDACC) patients in the derivation and validation cohorts with diverse baseline. At 6 months, the VTE incidence was 5.8% (VA), 8.2% (HHS), and 8.8% (MDACC), respectively. The corresponding estimates for PE/LE-DVT were 3.9% (VA), 4.5% (HHS), and 3.7% (MDACC), respectively. The variables in the final RAM included lymphoma histology, body mass index, therapy type, recent hospitalization, history of VTE, history of paralysis/immobilization, and time to treatment initiation. The RAM had c-statistics of 0.68 in the derivation and 0.69 and 0.72 in the two external validation cohorts. The two models achieved a clear differentiation in risk stratification in each cohort. Our findings suggest that easy-to-implement, clinical-based model could be used to predict personalized VTE risk for lymphoma patients.
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Affiliation(s)
- Shengling Ma
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX
| | - Jennifer La
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Kaitlin N Swinnerton
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
| | - Danielle Guffey
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX
| | | | - Giordana De Las Pozas
- Department of Cancer Registry, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katy Hanzelka
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xiangjun Xiao
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX
| | | | - Christopher I Amos
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX
- Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, TX
| | - Vipul Chitalia
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian and Advedisian School of Medicine, Boston, MA
- Institute of Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA
| | - Katya Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian and Advedisian School of Medicine, Boston, MA
| | - Kelly W Merriman
- Department of Cancer Registry, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher R Flowers
- Department of Lymphoma-Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nathanael R Fillmore
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Ang Li
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX
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Sánchez Prieto I, Gutiérrez Jomarrón I, Martínez Vázquez C, Rodríguez Barquero P, Gili Herreros P, García-Suárez J. Comprehensive evaluation of genetic and acquired thrombophilia markers for an individualized prediction of clinical thrombosis in patients with lymphoma and multiple myeloma. J Thromb Thrombolysis 2024:10.1007/s11239-024-02977-0. [PMID: 38676874 DOI: 10.1007/s11239-024-02977-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 04/29/2024]
Abstract
Patients diagnosed with lymphoma or multiple myeloma are at elevated risk of venous thromboembolism (VTE). Optimum risk stratification and effective thromboprophylaxis can only be achieved through the development of a multiple-specific risk score that successfully captures all aspects of the heterogeneous prothrombotic environment existing in these patients. Our aim was to identify risk factors for thrombosis and suggest an improved tool combining clinical data, thrombo-inflammatory biomarkers and genetic (Thrombo inCode® test) variables for predicting thrombotic risk in patients with lymphoma and multiple myeloma. A prospective longitudinal study was conducted on newly-diagnosed lymphoma and multiple myeloma patients who presented at our institution between February 2020 and January 2021. The study included 47 patients with lymphoma and 16 patients with multiple myeloma. We performed a follow-up of 1 year or until September 2021. The incidence of venous thrombosis and associated risk factors were analysed, including the genetic Thrombo inCode® test. Khorana and ThroLy scores for lymphoma patients and IMPEDE VTE score for myeloma patients were calculated. At a median follow-up of 9.1 months, VTE incidence was 9.5% (6/63), with 4 and 2 patients with lymphoma and myeloma who developed the events, respectively. Univariate analysis showed that the incidence of thrombosis was significantly higher in patients with ECOG ≥ 2 and prior immobility. Median factor VIII levels were significantly higher in patients with thrombosis (with increased values in all of them). Moreover, there was a trend in genetic variant rs5985 (factor XIII) as a protective factor, and a trend to higher thrombotic risk in patients with factor V Leiden, rs2232698 variant (serpinA10), low total protein S activity, elevated D-dimer, aggressive lymphoma and treatment with dexamethasone. The results of our study demonstrate promise for the potential use of widely accessible markers to increase precision in risk prediction for VTE in patients with lymphoma and multiple myeloma, particularly ECOG ≥ 2, immobility and higher factor VIII levels, as well as lymphoma aggressiveness, treatment with dexamethasone and the haemostatic biomarkers D-dimer and total protein S activity. Additionally, genetic variants factor V Leiden, serpinA10 rs2232698 and factor XIII-A Val34Leu warrant further investigation for use in the research setting.
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Affiliation(s)
- Irene Sánchez Prieto
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain.
| | - Isabel Gutiérrez Jomarrón
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Celia Martínez Vázquez
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Pedro Rodríguez Barquero
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Paula Gili Herreros
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Julio García-Suárez
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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Qin X, Gao X, Yang Y, Ou S, Luo J, Wei H, Jiang Q. Developing a risk assessment tool for cancer-related venous thrombosis in China: a modified Delphi-analytic hierarchy process study. BMC Cancer 2024; 24:120. [PMID: 38263026 PMCID: PMC10807161 DOI: 10.1186/s12885-024-11877-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/13/2024] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE To develop a Risk Assessment Tool for Cancer-related Venous Thrombosis in China. METHODS A modified two-round Delphi method was employed to establish consensus within a field to reach an agreement via a questionnaire or by interviewing a multidisciplinary panel of experts by collecting their feedback to inform the next round, exchanging their knowledge, experience, and opinions anonymously, and resolving uncertainties. Furthermore, The AHP (Analytic Hierarchy Process) was used to determine the final quality indicators' relative importance. RESULTS The expert's positive coefficient was 85.19% in the first round and 82.61% in the second round, with authoritative coefficients of 0.89 and 0.92 in the respective surveys. The P-value of Kendall's W test was all less than 0.001 for each round, and the W-value for concordance at the end of the two rounds was 0.115. The final Risk Assessment Tool for Cancer-related Venous Thrombosis consisted of three domains, ten subdomains, and 39 indicators, with patient factors weighing 0.1976, disease factors weighing 0.4905, and therapeutic factors weighing 0.3119. CONCLUSION The tool is significantly valid and reliable with a strong authority and coordination degree, and it can be used to assess the risk of cancer-related VTE and initiate appropriate thrombophylactic interventions in China.
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Affiliation(s)
- Xiaoli Qin
- Department of Pharmacy, The Third People's Hospital of Chengdu, 610031, Chengdu, Sichuan, P.R. China
- School of Pharmacy, Chengdu Medical College, 610500, Chengdu, Sichuan, P.R. China
| | - Xiurong Gao
- School of Pharmacy, Chengdu Medical College, 610500, Chengdu, Sichuan, P.R. China
| | - Yujie Yang
- Department of Pharmacy, The Third People's Hospital of Chengdu, 610031, Chengdu, Sichuan, P.R. China
| | - Shunlong Ou
- Department of Pharmacy, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, 610041, Chengdu, Sichuan, P.R. China
| | - Jing Luo
- Department of Pharmacy, The Second People's Hospital of Yibin, 644000, Yibin, Sichuan, P.R. China
| | - Hua Wei
- Department of Pharmacy, Chengdu Second People's Hospital, 610011, Chengdu, Sichuan, P.R. China
| | - Qian Jiang
- Department of Pharmacy, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, 610041, Chengdu, Sichuan, P.R. China.
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Drăgan A, Drăgan AŞ. Novel Insights in Venous Thromboembolism Risk Assessment Methods in Ambulatory Cancer Patients: From the Guidelines to Clinical Practice. Cancers (Basel) 2024; 16:458. [PMID: 38275899 PMCID: PMC10813930 DOI: 10.3390/cancers16020458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/07/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
Many cancer patients will experience venous thromboembolism (VTE) at some stage, with the highest rate in the initial period following diagnosis. Novel cancer therapies may further enhance the risk. VTE in a cancer setting is associated with poor prognostic, a decreased quality of life, and high healthcare costs. If thromboprophylaxis in hospitalized cancer patients and perioperative settings is widely accepted in clinical practice and supported by the guidelines, it is not the same situation in ambulatory cancer patient settings. The guidelines do not recommend primary thromboprophylaxis, except in high-risk cases. However, nowadays, risk stratification is still challenging, although many tools have been developed. The Khrorana score remains the most used method, but it has many limits. This narrative review aims to present the current relevant knowledge of VTE risk assessment in ambulatory cancer patients, starting from the guideline recommendations and continuing with the specific risk assessment methods and machine learning models approaches. Biomarkers, genetic, and clinical features were tested alone or in groups. Old and new models used in VTE risk assessment are exposed, underlining their clinical utility. Imaging and biomolecular approaches to VTE screening of outpatients with cancer are also presented, which could help clinical decisions.
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Affiliation(s)
- Anca Drăgan
- Department of Cardiovascular Anaesthesiology and Intensive Care, Emergency Institute for Cardiovascular Diseases “Prof. Dr. C C Iliescu”, 258 Fundeni Road, 022328 Bucharest, Romania
| | - Adrian Ştefan Drăgan
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania;
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Muñoz A, Ay C, Grilz E, López S, Font C, Pachón V, Castellón V, Martínez-Marín V, Salgado M, Martínez E, Calzas J, Ortega L, Rupérez A, Salas E, Pabinger I, Soria JM. A Clinical-Genetic Risk Score for Predicting Cancer-Associated Venous Thromboembolism: A Development and Validation Study Involving Two Independent Prospective Cohorts. J Clin Oncol 2023; 41:2911-2925. [PMID: 36730884 PMCID: PMC10414737 DOI: 10.1200/jco.22.00255] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 10/25/2022] [Accepted: 12/01/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Venous thromboembolism (VTE) is a leading cause of death among patients with cancer. The Khorana score was developed for assessing the risk of VTE in outpatients with cancer receiving chemotherapy, but its accuracy in identifying patients at high risk has been questioned. The aim of this study was to develop and validate a clinical-genetic score that improves the assessment of VTE risk in oncology outpatients within 6 months of diagnosis. METHODS The new score was developed using the data of 364 outpatients belonging to the Spanish ONCOTHROMB 12-01 population. In this cohort, clinical data associated with the risk of VTE were collected at the time of diagnosis, including the Khorana score. These patients were also genotyped for the 51 genetic variants known to be associated with VTE. Multivariate logistic regression was performed to determine the weight of each genetic and clinical variable in relation to VTE risk, allowing a clinical-genetic risk score (the ONCOTHROMB score) to be developed. The Khorana and the ONCOTHROMB scores were then compared via the area under the receiver operating characteristic curve (AUC), calibration, and the number of patients needed to treat. The new score was then validated in a study of 263 patients in the Vienna Cancer and Thrombosis Study population. RESULTS Nine genetic variants, tumor site, TNM stage, and a body mass index of > 25 kg/m2 were found to be associated with VTE and were used to build the ONCOTHROMB score, which better predicted the overall risk of VTE than did the Khorana score (AUC, 0.781 v 0.580; P < .001). Similar AUC results were recorded in the validation study the Vienna Cancer and Thrombosis Study cohort involving patients with the same type of tumor (AUC for the ONCOTHROMB score v the Khorana score: 0.686 v 0.577; P < .001) and with all type of tumors (AUC for the ONCOTHROMB score v the Khorana score: 0.720 v 0.561; P < .0001). CONCLUSION The ONCOTHROMB score for VTE risk in outpatients with cancer, which takes into account both clinical and genetic variables, better identifies patients who might benefit from primary thromboprophylaxis than does the Khorana score.
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Affiliation(s)
- Andrés Muñoz
- Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Ella Grilz
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sonia López
- Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - Carme Font
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Clínic, Barcelona, Spain
| | - Vanesa Pachón
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario Ramón y Cajal Madrid, Madrid, Spain
| | - Victoria Castellón
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Complejo Hospitalario de Torrecárdenas, Almería, Spain
| | - Virginia Martínez-Marín
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario La Paz, Madrid, Spain
| | - Mercedes Salgado
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Eva Martínez
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Julia Calzas
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Laura Ortega
- Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
| | - Ana Rupérez
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Fundación Jiménez Díaz, Madrid, Spain
| | - Eduardo Salas
- Scientific Department, Gendiag.exe, Barcelona, Spain
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Jose Manuel Soria
- Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
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Best practice & research: Clinical hematology review on thrombosis and bleeding in hematological malignancy. Best Pract Res Clin Haematol 2022; 35:101353. [DOI: 10.1016/j.beha.2022.101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 01/19/2023]
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Sanfilippo KM. Venous thromboembolism and risk stratification in hematological malignancies. Thromb Res 2022; 213 Suppl 1:S16-S21. [DOI: 10.1016/j.thromres.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/14/2021] [Accepted: 01/05/2022] [Indexed: 11/26/2022]
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Bastos-Oreiro M, Ortiz J, Pradillo V, Salas E, Marínez-Laperche C, Muñoz A, Buño I, Diéz-Martin JL, Soria JM, Pascual Izquierdo C. Incorporating genetic and clinical data into the prediction of thromboembolism risk in patients with lymphoma. Cancer Med 2021; 10:7585-7592. [PMID: 34598309 PMCID: PMC8559493 DOI: 10.1002/cam4.4280] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 08/14/2021] [Accepted: 08/26/2021] [Indexed: 12/21/2022] Open
Abstract
Background The incorporation of genetic variables into risk scores for predicting venous thromboembolic events (VTE) could improve their capacity to identify those patients for whom thromboprophylaxis would be most beneficial. Proof‐of‐concept of this is provided by the TiC‐ONCO score for predicting the risk of VTE in patients with solid tumours. Our aim was to develop a similarly improved tool—the TiC‐LYMPHO score—for predicting VTE in patients with lymphoma. Methods In a retrospective observational study of 208 patients with lymphoma, 31 (14.9%) were found to have experienced an episode of VTE either at the time of diagnosis or over the next 6 months. Clinical variables associated with VTE, determined via logistic regression analysis, plus the same genetic variables included in the TiC‐ONCO score, were used to build the TiC‐LYMPHO score algorithm. The sensitivity, specificity, predictive values and AUC of the TiC‐LYMPHO, the Khorana and ThroLy scores were compared in the same population. Results The TiC‐LYMPHO score showed a significantly higher AUC, sensitivity and NPV (0.783, 95.35% and 97.98% respectively) than the other scores. The ThroLy score showed a significantly higher specificity (96.43% vs. 54.49%; p < 0.0001) and PPV (37.50% vs. 26.36%; p = 0.0147) than the TiC‐LYMPHO score, whereas its AUC, sensitivity and NPV were significantly lower (0.579, 19.35% and 86.48%, respectively). Conclusion These results show that by incorporating genetic and clinical data into VTE risk assessment, the TiC‐LYMPHO score can categorize patients with lymphoma better in terms of their risk of VTE and allow individualized thromboprophylaxis to be prescribed.
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Affiliation(s)
- Mariana Bastos-Oreiro
- Hematology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Genomics Unit, Hospital General Universitario. Gregorio Marañón, Madrid, Spain.,Cell Biology Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Ortiz
- Hematology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Virginia Pradillo
- Hematology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Eduardo Salas
- Gendiag, S.L. Scientific Department, Barcelona, Spain
| | - Carolina Marínez-Laperche
- Hematology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Andrés Muñoz
- Oncology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ismael Buño
- Hematology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - José Luis Diéz-Martin
- Hematology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Jose Manuel Soria
- Hospital Universitario de la Santa Creu I Santa Pau, Barcelona, Spain
| | - Cristina Pascual Izquierdo
- Hematology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
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