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Spannbauer A, Bergler-Klein J. Cardio-Oncology: A New Discipline in Medicine and Its Relevance to Hematology. Hamostaseologie 2024; 44:255-267. [PMID: 38723641 DOI: 10.1055/a-2284-5855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024] Open
Abstract
Cardio-oncology, a burgeoning subspecialty, addresses the complex interplay between cardiology and oncology, particularly in light of increased cardiovascular (CV) disease mortality in cancer patients. This review provides a comprehensive overview of cardio-oncology with a focus on the therapies used in hematological malignancies. We explore the bidirectional relationship between heart failure and cancer, emphasizing the need for collaborative care. The review discusses risk stratification, highlighting the importance of baseline CV risk assessment and personalized surveillance regimens. Primary and secondary prevention strategies, including pharmacological interventions, are outlined. The review also delves into the cardiotoxicity associated with hematological cancer therapies, focusing on anthracyclines, Bruton kinase inhibitors, BCR-ABL tyrosine kinase inhibitors, CAR-T cell therapy, immune checkpoint inhibitors, multiple myeloma treatments, and hematopoietic stem cell transplantation. We then highlight the high risk of venous and arterial thromboembolisms in cancer patients and the challenges of anticoagulation management in cardio-oncology. Finally, the review touches on the importance of long-term follow-up and appropriate screening in cancer survivors at high risk of CV morbidity and mortality, based on their CV risk profile and the type and dose of cardiotoxic therapies they received such as anthracyclines or high radiation doses.
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Athanasopoulos M, Nomikos G, Samara P, Mastronikolis S, Tsilivigkos C, Mastronikolis NS. Non‑Hodgkin's lymphomas of the lacrimal sac: Current insights and future directions (Review). MEDICINE INTERNATIONAL 2024; 4:43. [PMID: 38912417 PMCID: PMC11190882 DOI: 10.3892/mi.2024.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/31/2024] [Indexed: 06/25/2024]
Abstract
Non-Hodgkin's lymphoma (NHL) of the lacrimal sac is a rare, yet clinically significant entity within the spectrum of ocular malignancies. While primary lacrimal sac lymphoma is uncommon, it poses unique diagnostic and therapeutic challenges due to its anatomical location and potential for aggressive behavior. Despite advancements being made in the current understanding and treatment of NHL, research that specifically addresses the involvement of the lacrimal sac is currently lacking. Thus, the present review aimed to provide insight into the epidemiology, clinical presentation, diagnostic modalities, histopathological features, treatment strategies and prognosis of lacrimal sac NHL. Through a methodical analysis of previous literature, the present review highlights the diverse spectrum of NHL subtypes that affect the lacrimal sac, including diffuse large B-cell lymphoma, extranodal marginal zone lymphoma, mantle cell lymphoma and follicular lymphoma. Moreover, the present review discusses the role of advanced imaging techniques in accurate staging and treatment planning, including computed tomography (CT), magnetic resonance imaging and positron emission tomography-CT. The present review also discusses evolving treatment approaches, such as surgical intervention, chemotherapy, radiotherapy, immunotherapy, combinations of the aforementioned treatments and targeted therapy. In addition, the present review highlights the significance of multidisciplinary collaboration in attaining optimal outcomes for individuals with lacrimal sac NHL. The present review aimed to provide a basis for 'further investigations into novel treatment modalities and prognostic markers that may aid in guiding personalized management strategies, ultimately improving outcomes for patients with NHL.
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Affiliation(s)
| | - Georgios Nomikos
- Department of Otolaryngology, General Hospital of Nikaia, Piraeus ‘Agios Panteleimon’, 18454 Athens, Greece
| | - Pinelopi Samara
- Children's Oncology Unit Marianna V. Vardinoyannis-ELPIDA, Aghia Sophia Children's Hospital, 11527 Athens, Greece
| | | | - Christos Tsilivigkos
- 1st Department of Otolaryngology, Hippocrateion Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Yamasaki S. Appropriate Treatment Intensity for Diffuse Large B-Cell Lymphoma in the Older Population: A Review of the Literature. Hematol Rep 2024; 16:317-330. [PMID: 38921180 PMCID: PMC11204029 DOI: 10.3390/hematolrep16020032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024] Open
Abstract
Most patients with diffuse large B-cell lymphoma (DLBCL) are >65 years of age, with the number of patients expected to increase in the coming years. A comprehensive geriatric assessment that carefully evaluates fitness status and comorbidities is essential for selecting the appropriate treatment intensity. Although generally healthy patients or those <80 years of age may benefit from standard immunochemotherapy, unfit/frail patients or patients >80 years old may require reduced-intensity chemotherapy or less-toxic drugs. Some new drugs are currently being tested as single or combined agents for first-line treatment, aiming to improve the outcomes of conventional chemotherapy. This review systematically collates and discusses the outcomes associated with the use of immunochemotherapy in older patients with DLBCL, as well as considering the impact of full-dose immunochemotherapy on quality of life in older and frail patients, summarizing the rationale for reduced dosing in the older population, and presenting recommendations for selecting patients likely to benefit from reduced dosing. If preliminary efficacy and safety data are confirmed in future clinical trials, non-chemotherapy-based immunotherapy approaches could become an alternative potentially curative option in frail patients and those >80 years of age with DLBCL.
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Affiliation(s)
- Satoshi Yamasaki
- Department of Hematology, St. Mary’s Hospital, 422 Tsubukuhonmachi, Kurume 830-8543, Japan; ; Tel.: +81-942-35-3322; Fax: +81-9442-34-3115
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu 874-0838, Japan
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka 810-0065, Japan
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Tucci A, Masina L, Luminari S. Curative intent therapy for DLBCL in the elderly. Leuk Lymphoma 2024; 65:560-569. [PMID: 38206922 DOI: 10.1080/10428194.2024.2302323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024]
Abstract
Older patients with aggressive lymphoma are extremely heterogeneous due to the high frequency of functional limitations and comorbidities and to the different biological profiles and clinical behavior of the disease. The stratification in three geriatric categories (fit-unfit-frail) based on multidimensional geriatric assessment (GA) helps physicians tailor a potentially curative treatment.While an intensive approach with the standard R-CHOP regimen is feasible in fit patients, leading to similar long-term response and survival rates compared to younger ones, in unfit patients a balance between treatment toxicity and curative intent can be obtained through the reduction of dose intensity. Frail patients, treated with best supportive care so far, could benefit from a chemo-free approach with new target drugs. These novel agents, either alone or in combination with chemo-immunotherapy, are changing the therapeutic landscape of older patients with aggressive lymphoma, both in first-line therapy and in the setting of the relapsed/refractory disease.
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Affiliation(s)
| | | | - Stefano Luminari
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
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Mu K, Zhang J, Gu Y, Huang G. Development and validation of a nomogram for predicting cardiovascular mortality risk for diffuse large B-cell lymphoma in children, adolescents, and adults. Front Pediatr 2024; 12:1346006. [PMID: 38384660 PMCID: PMC10879433 DOI: 10.3389/fped.2024.1346006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Objective This study aimed to construct and validate a nomogram for predicting cardiovascular mortality (CVM) for child, adolescent, and adult patients with diffuse large B-cell lymphoma (DLBCL). Materials and methods Patients with only one primary tumor of DLBCL first diagnosed between 2000 and 2019 in the SEER database were extracted. We used the cumulative incidence function (CIF) to evaluate the cumulative rate of CVM. The outcome of interest was CVM, which was analyzed using a competing risk model, accounting for death due to other causes. The total database was randomly divided into a training cohort and an internal validation cohort at a ratio of 7:3. Adjustments were for demographics, tumor characteristics, and treatment modalities. Nomograms were constructed according to these risk factors to predict CVM risk at 5, 10, and 15 years. Validation included receiver operating characteristic (ROC) curves, time-dependent ROC, C-index, calibration curves, and decision curve analysis. Results One hundred four thousand six hundred six patients following initial diagnosis of DLBCL were included (58.3% male, median age 64 years, range 0-80, White 83.98%). Among them, 5.02% died of CVM, with a median follow-up time of 61 (31-98) months. Nomograms based on the seven risk factors (age at diagnosis, gender, race, tumor grade, Ann Arbor stage, radiation, chemotherapy) with hazard ratios ranging from 0.19-1.17 showed excellent discrimination, and calibration plots demonstrated satisfactory prediction. The 5-, 10-, and 15-year AUC and C-index of CVM in the training set were 0.716 (0.714-0.718), 0.713 (0.711-0.715), 0.706 (0.704-0.708), 0.731, 0.727, and 0.719; the corresponding figures for the validation set were 0.705 (0.688-0.722), 0.704 (0.689-0.718), 0.707 (0.693-0.722), 0.698, 0.698, and 0.699. Decision curve analysis revealed a clinically beneficial net benefit. Conclusions We first built the nomogram model for DLBCL patients with satisfactory prediction and excellent discrimination, which might play an essential role in helping physicians enact better treatment strategies at the time of initial diagnosis.
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Affiliation(s)
- Kai Mu
- Pediatric Heart Center, Children’s Hospital of Fudan University, Shanghai, China
- Department of Pediatric, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Jing Zhang
- Department of Pediatric, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yan Gu
- Department of Pediatric, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Guoying Huang
- Pediatric Heart Center, Children’s Hospital of Fudan University, Shanghai, China
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Chen Q, Thompson J, Hu Y, Lesnefsky EJ. Endoplasmic reticulum stress and alterations of peroxiredoxins in aged hearts. Mech Ageing Dev 2023; 215:111859. [PMID: 37661065 PMCID: PMC11103240 DOI: 10.1016/j.mad.2023.111859] [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: 04/18/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Abstract
Aging-related cardiovascular disease is influenced by multiple factors, with oxidative stress being a key contributor. Aging-induced endoplasmic reticulum (ER) stress exacerbates oxidative stress by impairing mitochondrial function. Furthermore, a decline in antioxidants, including peroxiredoxins (PRDXs), augments the oxidative stress during aging. To explore if ER stress leads to PRDX degradation during aging, young adult (3 mo.) and aged (24 mo.) male mice were studied. Treatment with 4-phenylbutyrate (4-PBA) was used to alleviate ER stress in young adult and aged mice. Aged hearts showed elevated oxidative stress levels compared to young hearts. However, treatment with 4-PBA to attenuate ER stress reduced oxidative stress in aged hearts, indicating that ER stress contributes to increased oxidative stress in aging. Moreover, aging resulted in reduced levels of peroxiredoxin 3 (PRDX3) in mitochondria and peroxiredoxin 4 (PRDX4) in myocardium. While 4-PBA treatment improved PRDX3 content in aged hearts, it did not restore PRDX4 content in aged mice. These findings suggest that ER stress not only leads to mitochondrial dysfunction and increased oxidant stress but also impairs a vital antioxidant defense through decreased PRDX3 content. Additionally, the results suggest that PRDX4 may contribute an upstream role in inducing ER stress during aging.
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Affiliation(s)
- Qun Chen
- Departments of Medicine (Division of Cardiology), Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Jeremy Thompson
- Departments of Medicine (Division of Cardiology), Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Ying Hu
- Departments of Medicine (Division of Cardiology), Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Edward J Lesnefsky
- Departments of Medicine (Division of Cardiology), Virginia Commonwealth University, Richmond, VA 23298, USA; Biochemistry and Molecular Biology, Virginia Commonwealth University, Richmond, VA 23298, USA; Physiology and Biophysics, Virginia Commonwealth University, Richmond, VA 23298, USA; Richmond Department of Veterans Affairs Medical Center, Richmond, VA 23249, USA.
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Rihackova E, Rihacek M, Vyskocilova M, Valik D, Elbl L. Revisiting treatment-related cardiotoxicity in patients with malignant lymphoma-a review and prospects for the future. Front Cardiovasc Med 2023; 10:1243531. [PMID: 37711551 PMCID: PMC10499183 DOI: 10.3389/fcvm.2023.1243531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
Treatment of malignant lymphoma has for years been represented by many cardiotoxic agents especially anthracyclines, cyclophosphamide, and thoracic irradiation. Although they are in clinical practice for decades, the precise mechanism of cardiotoxicity and effective prevention is still part of the research. At this article we discuss most routinely used anti-cancer drugs in chemotherapeutic regiments for malignant lymphoma with the focus on novel insight on molecular mechanisms of cardiotoxicity. Understanding toxicity at molecular levels may unveil possible targets of cardioprotective supportive therapy or optimization of current therapeutic protocols. Additionally, we review novel specific targeted therapy and its challenges in cardio-oncology.
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Affiliation(s)
- Eva Rihackova
- Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine of Masaryk University, Brno, Czech Republic
| | - Michal Rihacek
- Department of Laboratory Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Maria Vyskocilova
- Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine of Masaryk University, Brno, Czech Republic
| | - Dalibor Valik
- Department of Laboratory Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lubomir Elbl
- Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine of Masaryk University, Brno, Czech Republic
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Arcari A, Rigacci L, Tucci A, Puccini B, Usai SV, Cavallo F, Fabbri A, Balzarotti M, Pelliccia S, Luminari S, Pennese E, Zilioli VR, Mahmoud AM, Musuraca G, Marino D, Sartori R, Botto B, Gini G, Zanni M, Hohaus S, Tarantini G, Flenghi L, Tani M, Di Rocco A, Merli M, Vallisa D, Pagani C, Nassi L, Dessì D, Ferrero S, Cencini E, Bernuzzi P, Mammi C, Marcheselli L, Tabanelli V, Spina M, Merli F. A Fondazione Italiana Linfomi cohort study of R-COMP vs R-CHOP in older patients with diffuse large B-cell lymphoma. Blood Adv 2023; 7:4160-4169. [PMID: 37276080 PMCID: PMC10407138 DOI: 10.1182/bloodadvances.2023009839] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/11/2023] [Accepted: 05/14/2023] [Indexed: 06/07/2023] Open
Abstract
Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is the most commonly used regimen for the upfront treatment of diffuse large B-cell lymphoma (DLBCL). However, it is associated with cardiotoxicity, especially in older patients. Substituting doxorubicin with non-PEGylated liposomal doxorubicin (R-COMP) may reduce the risk of cardiac events, but its efficacy has never been demonstrated in prospective trials. We describe the characteristics and outcome of patients with DLBCL aged ≥65 years prospectively enrolled in the Elderly Project by the Fondazione Italiana Linfomi and treated with full doses of R-CHOP or R-COMP per local practice. Starting from 1163 patients, 383 (55%) were treated with R-CHOP and 308 (45%) with R-COMP. Patients treated with R-COMP were older (median age, 76 vs 71 years), less frequently fit at simplified geriatric assessment (61% vs 88%; P < .001), and had a more frequent baseline cardiac disorders (grade >1, 32% vs 8%; P < .001). Three-year progression-free survival (PFS) was similar between R-CHOP and R-COMP (70% and 64%); 3-year overall survival was 77%, and 71% respectively. R-CHOP was associated with better PFS vs R-COMP only in the Elderly Prognostic Index (EPI) low-risk group. The two groups had similar rates of treatment interruptions due to toxicities or of cardiac events (P = 1.00). We suggest R-COMP is a potentially curative treatment for older patients with intermediate- or high-risk EPI, even in the presence of a baseline cardiopathy. R-CHOP is confirmed as the standard therapy for low risk patients.
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Affiliation(s)
- Annalisa Arcari
- Hematology Unit, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Lugi Rigacci
- UOC Hematology and Stem Cell Transplantation, AO San Camillo Forlanini, Roma, Italy
| | - Alessandra Tucci
- Hematology Division, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Benedetta Puccini
- Lymphoma Unit, Hematology Department, Careggi Hospital and University of Florence, Firenze, Italy
| | - Sara Veronica Usai
- Division of Hematology, Ospedale Oncologico Armando Businco, Cagliari, Italy
| | - Federica Cavallo
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino/AOU “Città della Salute e della Scienza di Torino,” Torino, Italy
| | - Alberto Fabbri
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena, Italy
| | - Monica Balzarotti
- Department of Medical Oncology and Hematology, Humanitas Clinical Research Hospital Istituto di Ricovero e Cura a Carattere Scientifico, Rozzano, Milan, Italy
| | - Sabrina Pelliccia
- Hematology, Department of Clinical and Molecular Medicine, University Hospital Sant’Andrea, Sapienza University of Rome, Rome, Italy
| | - Stefano Luminari
- Hematology Unit, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Department CHIMOMO, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Elsa Pennese
- Lymphoma Unit, Department of Hematology, Ospedale Spirito Santo, Pescara, Italy
| | | | | | - Gerardo Musuraca
- Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori “Dino Amadori,” Meldola, Forlì-Cesena, Italy
| | - Dario Marino
- Department of Clinical and Experimental Oncology, Medical Oncology 1, Veneto Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico, Padova, Italy
| | - Roberto Sartori
- Oncohematology Unit, Veneto Institute of Oncology, Veneto Institute of Oncology Istituto di Ricovero e Cura a Carattere Scientifico, Castelfranco Veneto, Treviso, Italy
| | - Barbara Botto
- Division of Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
| | - Guido Gini
- Division of Hematology, Azienda Ospedaliera Universitaria Ospedali Riuniti, Ancona, Italy
| | - Manuela Zanni
- Hematology Unit, Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Stefan Hohaus
- University Policlinico Gemelli Foundation Istituto di Ricovero e Cura a Carattere Scientifico, Catholic University of the Sacred Heart, Roma, Italy
| | - Giuseppe Tarantini
- Haematology and Bone Marrow Transplant Unit, Ospedale Monsignor R. Dimiccoli, Barletta, Italy
| | - Leonardo Flenghi
- Hematology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Monica Tani
- Hematology Unit, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Alice Di Rocco
- Institute of Hematology, Department of Translational and Precision Medicine “Sapienza,” University of Roma, Roma, Italy
| | - Michele Merli
- Division of Hematology, Ospedale di Circolo e Fondazione Macchi ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Daniele Vallisa
- Hematology Unit, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Chiara Pagani
- Hematology Division, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Luca Nassi
- Lymphoma Unit, Hematology Department, Careggi Hospital and University of Florence, Firenze, Italy
| | - Daniela Dessì
- Division of Hematology, Ospedale Oncologico Armando Businco, Cagliari, Italy
| | - Simone Ferrero
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino/AOU “Città della Salute e della Scienza di Torino,” Torino, Italy
| | - Emanuele Cencini
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena, Italy
| | | | - Caterina Mammi
- Gruppo Amici dell'Ematologia GRADE Onlus Foundation, Reggio Emilia, Italy
| | | | - Valentina Tabanelli
- Division of Haematopathology, European Institute of Oncology IRCCS, Milan, Italy
| | - Michele Spina
- Division of Medical Oncology and Immune-related Tumors, Centro di Riferimento Oncologico di Aviano IRCCS, Aviano, Pordenone, Italy
| | - Francesco Merli
- Hematology Unit, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Arcari A, Cavallo F, Puccini B, Vallisa D. New treatment options in elderly patients with Diffuse Large B-cell Lymphoma. Front Oncol 2023; 13:1214026. [PMID: 37465115 PMCID: PMC10351275 DOI: 10.3389/fonc.2023.1214026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/18/2023] [Indexed: 07/20/2023] Open
Abstract
Most patients with Diffuse Large B-cell Lymphoma (DLBCL) are old (>65 years of age) and this population is expected to increase in the following years. A simplified geriatric assessment based on a careful evaluation of the fitness status and comorbidities is essential to choose the correct intensity of treatment. Fit older patients can benefit from a standard immunochemotherapy, while unfit/frail patients frequently need reduced doses or substitution of particular agents with less toxic ones. This review focuses on new therapies (e.g., polatuzumab vedotin, tafasitamab, bispecific antibodies) that have indicated promising results in relapsed/refractory patients, particularly in cases not eligible to transplant. Some of these new drugs have been tested as single agents or in combinations as first-line treatment, aiming to improve the outcome of the traditional chemotherapy. If preliminary efficacy and safety data are confirmed in future clinical trials, a chemo-free immunotherapic approach could become an alternative option to offer a curative treatment even in frail patients.
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Affiliation(s)
- Annalisa Arcari
- Hematology and Bone Marrow Transplant Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Federica Cavallo
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino/Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza di Torino, Torino, Italy
| | - Benedetta Puccini
- Hematology Department, University of Florence and Azienda Ospedaliera Universitaria (AOU) Careggi, Firenze, Italy
| | - Daniele Vallisa
- Hematology and Bone Marrow Transplant Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
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R-CEOP as first-line treatment for anthracycline-ineligible patients with diffuse large B-cell lymphoma. Blood Cancer J 2022; 12:125. [PMID: 36055987 PMCID: PMC9440142 DOI: 10.1038/s41408-022-00723-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 11/08/2022] Open
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Gao H, Liu Y, Xu Y, Mi L, Zhang C, Wang X, Song Y, Zhu J, Liu W. Impact of relative dose intensity of R-CCOP regimen in elderly patients with diffuse large B-cell lymphoma in China. J Formos Med Assoc 2022; 121:2556-2565. [PMID: 35787343 DOI: 10.1016/j.jfma.2022.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/01/2022] [Accepted: 06/08/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The actual relative dose intensity (RDI) of the attenuated R-CCOP regimen (rituximab, cytoxan, pegylated liposomal doxorubicin [PLD], vincristine, and prednisone) has not been fully investigated in Chinese geriatric patients with diffuse large B-cell lymphoma (DLBCL). In particular, the optimum dose for PLD remains unclear. METHODS We retrospectively collected clinical data from patients with untreated DLBCL aged 65-80 years subsequently treated with the R-CCOP. The restricted cubic spline model (RCS) was used to test the non-linear relationship between the predictors and outcomes. RESULTS Eighty-four patients were enrolled, with a median age of 73.5 years. More than half of the patients (54.8%) received at least 6 cycles. The median dose per cycle of cytoxan and PLD were 605.5 and 19.9 mg/m2. The 5-year progression-free survival (PFS), overall survival rate, and disease-specific survival rates were 38.7%, 44.8%, and 57.2%, respectively. The RDI of PLD (PLD-RDI, <70% vs ≥ 70%) was only significant in the univariate analysis (P = 0.002) but not in the multivariate analysis. The RCS model showed a decreasing trend of hazards with an increasing PLD dose per cycle after adjustment. No significant difference was observed between the low- and high-risk groups with PLD-RDI ≥ 70% (P = 0.548). However, patients in the high-risk group had unfavorable PFS with PLD-RDI < 70% (P = 0.006). CONCLUSION The optimal dose of PLD for elderly patients with DLBCL in China remains to be determined. Evaluating the tolerance and identifying risk categories are critical for clinical decision-making in this population.
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Affiliation(s)
- Hongye Gao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Lymphoma, Peking University Cancer Hospital & Institute, No. 52 Fucheng Road, Haidian District, Beijing 100142, China
| | - Yanfei Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Lymphoma, Peking University Cancer Hospital & Institute, No. 52 Fucheng Road, Haidian District, Beijing 100142, China
| | - Yanfeng Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Lymphoma, Peking University Cancer Hospital & Institute, No. 52 Fucheng Road, Haidian District, Beijing 100142, China
| | - Lan Mi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Lymphoma, Peking University Cancer Hospital & Institute, No. 52 Fucheng Road, Haidian District, Beijing 100142, China
| | - Chen Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Lymphoma, Peking University Cancer Hospital & Institute, No. 52 Fucheng Road, Haidian District, Beijing 100142, China
| | - Xiaopei Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Lymphoma, Peking University Cancer Hospital & Institute, No. 52 Fucheng Road, Haidian District, Beijing 100142, China
| | - Yuqin Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Lymphoma, Peking University Cancer Hospital & Institute, No. 52 Fucheng Road, Haidian District, Beijing 100142, China
| | - Jun Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Lymphoma, Peking University Cancer Hospital & Institute, No. 52 Fucheng Road, Haidian District, Beijing 100142, China.
| | - Weiping Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Lymphoma, Peking University Cancer Hospital & Institute, No. 52 Fucheng Road, Haidian District, Beijing 100142, China.
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12
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Puckrin R, Ghosh S, Peters A, Stewart D. Inferior outcomes with R-CEOP for patients with diffuse large B-cell lymphoma and cardiovascular comorbidities. Leuk Lymphoma 2021; 63:583-590. [PMID: 34672241 DOI: 10.1080/10428194.2021.1992762] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Anthracycline-based chemoimmunotherapy with R-CHOP is the standard treatment for diffuse large B-cell lymphoma (DLBCL) but is associated with increased risks of cardiotoxicity. The alternative regimen R-CEOP substitutes etoposide for doxorubicin and is commonly administered to DLBCL patients with cardiovascular comorbidities, although there is limited evidence supporting its use. This multicenter real-world study included 138 consecutive patients with newly-diagnosed DLBCL treated with R-CEOP and 414 patients treated with R-CHOP matched 1:3 for age and International Prognostic Index. With median follow-up time 4.6 years, R-CEOP was associated with significantly inferior 4-year progression-free survival (32 vs. 52%, p < 0.0001), overall survival (39 vs. 59%, p < 0.0001), and disease-specific survival (48 vs. 69%, p < 0.0001) compared to R-CHOP. R-CHOP should remain the preferred regimen for most patients with DLBCL. While R-CEOP may be a reasonable choice for patients strictly ineligible for anthracyclines, the inferior outcomes of this regimen suggest that this high-risk population requires novel therapeutic approaches.
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Affiliation(s)
- Robert Puckrin
- Postgraduate Medical Education, University of Calgary and Tom Baker Cancer Centre, Calgary, Canada, Canada
| | - Sunita Ghosh
- Alberta Health Services Cancer Control Alberta, Edmonton, Canada
| | - Anthea Peters
- Department of Oncology, University of Alberta and Cross Cancer Institute, Edmonton, Canada
| | - Douglas Stewart
- Department of Oncology, University of Calgary and Tom Baker Cancer Centre, Calgary, Canada
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13
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Schettini F, Giuliano M, Lambertini M, Bartsch R, Pinato DJ, Onesti CE, Harbeck N, Lüftner D, Rottey S, van Dam PA, Zaman K, Mustacchi G, Gligorov J, Awada A, Campone M, Wildiers H, Gennari A, Tjan-Heijnen VCG, Cortes J, Locci M, Paris I, Del Mastro L, De Placido S, Martín M, Jerusalem G, Venturini S, Curigliano G, Generali D. Anthracyclines Strike Back: Rediscovering Non-Pegylated Liposomal Doxorubicin in Current Therapeutic Scenarios of Breast Cancer. Cancers (Basel) 2021; 13:4421. [PMID: 34503231 PMCID: PMC8430783 DOI: 10.3390/cancers13174421] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 12/12/2022] Open
Abstract
Anthracyclines are among the most active chemotherapies (CT) in breast cancer (BC). However, cardiotoxicity is a risk and peculiar side effect that has been limiting their use in clinical practice, especially after the introduction of taxanes. Non-pegylated liposomal doxorubicin (NPLD) has been developed to optimize the toxicity profile induced by anthracyclines, while maintaining its unquestionable therapeutic index, thanks to its delivering characteristics that increase its diffusion in tumor tissues and reduce it in normal tissues. This feature allows NPLD to be safely administered beyond the standard doxorubicin maximum cumulative dose of 450-480 mg/m2. Following three pivotal first-line phase III trials in HER2-negative metastatic BC (MBC), this drug was finally approved in combination with cyclophosphamide in this specific setting. Given the increasing complexity of the therapeutic scenario of HER2-negative MBC, we have carefully revised the most updated literature on the topic and dissected the potential role of NPLD in the evolving therapeutic algorithms.
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Affiliation(s)
- Francesco Schettini
- Translational Genomics and Targeted Therapies in Solid Tumors Research Group, 08036 Barcelona, Spain;
- Department of Medical Oncology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Mario Giuliano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy; (M.G.); (S.D.P.)
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, 16132 Genova, Italy; (M.L.); (L.D.M.)
- Department of Medical Oncology, U.O.C Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Rupert Bartsch
- Division of Oncology, Department of Medicine 1, Medical University of Vienna, 1090 Vienna, Austria;
| | - David James Pinato
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
- Department of Translational Medicine, Università del Piemonte Orientale “A. Avogadro”, 28100 Novara, Italy;
| | - Concetta Elisa Onesti
- Clinical and Oncological Research Department, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy;
| | - Nadia Harbeck
- Breast Center, Department OB&GYN and CCCLMU, LMU University Hospital, 81377 Munich, Germany;
| | - Diana Lüftner
- Department of Hematology, Oncology and Tumor Immunology, Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Sylvie Rottey
- Department of Medical Oncology, UZ Gent, 9000 Gent, Belgium;
| | - Peter A. van Dam
- Oncology Department, University Hospital Antwerp (UZA), 2650 Edegem, Belgium;
| | - Khalil Zaman
- Oncology Department, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland;
| | - Giorgio Mustacchi
- Division of Medical Oncology, University of Trieste, 34127 Trieste, Italy;
| | - Joseph Gligorov
- Department of Medical Oncology, Tenon Hospital, Institut Universitaire de Cancérologie AP-HP, Sorbonne University, 75004 Paris, France;
| | - Ahmad Awada
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Bruxelles, Belgium;
| | - Mario Campone
- Division of Medical Oncology, Institut de Cancérologie de l’Ouest-Pays de la Loire, 44800 Saint-Herblain, France;
| | - Hans Wildiers
- Department of General Medical Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
| | - Alessandra Gennari
- Department of Translational Medicine, Università del Piemonte Orientale “A. Avogadro”, 28100 Novara, Italy;
| | - Vivianne C. G. Tjan-Heijnen
- Division of Medical Oncology, Maastricht University Medical Center (MUMC), 6229 Maastricht, The Netherlands;
| | - Javier Cortes
- Oncology Department, IOB Institute of Oncology, Quiron Group, 08023 Madrid, Spain;
- Vall d’Hebron Institute of Oncology (VHIO), Centro Cellex, 08035 Carrer de Natzaret, Spain
| | - Mariavittoria Locci
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, 80131 Naples, Italy;
| | - Ida Paris
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A, Gemelli IRCCS, 00168 Rome, Italy;
| | - Lucia Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, 16132 Genova, Italy; (M.L.); (L.D.M.)
- Department of Medical Oncology, U.O.C Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy; (M.G.); (S.D.P.)
| | - Miguel Martín
- Departamento de Medicina, Instituto de Investigación Sanitaria Gregorio Marañón Universidad Complutense, 28007 Madrid, Spain;
| | - Guy Jerusalem
- Division of Medical Oncology, CHU Sart Tilman Liège and University of Liège, 4000 Liège, Belgium;
| | - Sergio Venturini
- Management Department, University of Turin, 10124 Torino, Italy;
| | - Giuseppe Curigliano
- Istituto Europeo di Oncologia, IRCCS ed Università di Milano, 20141 Milano, Italy;
| | - Daniele Generali
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34127 Trieste, Italy
- Multidisciplinary Unit of Breast Pathology and Translational Research, Cremona Hospital, Viale Concordia 1, 26100 Cremona, Italy
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14
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Su X, Zhang X, Liu W, Yang X, An N, Yang F, Sun J, Xing Y, Shang H. Advances in the application of nanotechnology in reducing cardiotoxicity induced by cancer chemotherapy. Semin Cancer Biol 2021; 86:929-942. [PMID: 34375726 DOI: 10.1016/j.semcancer.2021.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 02/08/2023]
Abstract
Advances in the development of anti-tumour drugs and related technologies have resulted in a significant increase in the number of cancer survivors. However, the incidence of chemotherapy-induced cardiotoxicity (CIC) has been rising continuously, threatening their long-term survival. The integration of nanotechnology and biomedicine has brought about an unprecedented technological revolution and has promoted the progress of anti-tumour therapy. In this review, we summarised the possible mechanisms of CIC, evaluated the role of nanoparticles (including liposomes, polymeric micelles, dendrimers, and hydrogels) as drug carriers in preventing cardiotoxicity and proposed five advantages of nanotechnology in reducing cardiotoxicity: Liposomes cannot easily penetrate the heart's endothelial barrier; optimized delivery strategies reduce distribution in important organs, such as the heart; targeting the tumour microenvironment and niche; stimulus-responsive polymer nano-drug carriers rapidly iterate; better economic benefits were obtained. Nanoparticles can effectively deliver chemotherapeutic drugs to tumour tissues, while reducing the toxicity to heart tissues, and break through the dilemma of existing chemotherapy to a certain extent. It is important to explore the interactions between the physicochemical properties of nanoparticles and optimize the highly specific tumour targeting strategy in the future.
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Affiliation(s)
- Xin Su
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaoyu Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Wenjing Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xinyu Yang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Na An
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Fan Yang
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jiahao Sun
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanwei Xing
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China; College of Integrated Traditional Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China.
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15
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Visco C, Pregnolato F, Ferrarini I, De Marco B, Bonuomo V, Sbisà E, Fraenza C, Bernardelli A, Tanasi I, Quaglia FM, Krampera M. Efficacy of R-COMP in comparison to R-CHOP in patients with DLBCL: A systematic review and single-arm metanalysis. Crit Rev Oncol Hematol 2021; 163:103377. [PMID: 34087342 DOI: 10.1016/j.critrevonc.2021.103377] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/21/2021] [Accepted: 05/29/2021] [Indexed: 11/29/2022] Open
Abstract
Doxorubicin represents the mainstay in the upfront treatment of diffuse large B-cell lymphoma (DLBCL) patients. However, its administration is sometimes hampered by the coexistence of former comorbidities/cardiac issues, especially in the elderly population. Liposome encapsulated drug delivery systems have been adopted to reduce the exposure of normal tissues to the drug, both in solid cancers and lymphomas. Despite claims for lower toxicity, the efficacy of non-pegylated liposome doxorubicin (NPLD) in DLBCL, as compared to standard doxorubicin, has never been established. We systematically reviewed relevant literature of NPLD in lymphoma treatment. Adjusting for age/comorbidities, our metanalysis revealed that the use of combinations including NPLD (R-COMP) were non-inferior in terms of response, overall and progression-free survival to the standard of care (R-CHOP) in overlapping series of DLBCL patients. R-COMP may represent a safe and active option for elderly patients with DLBCL, or for those with some extent of cardiac impairment at baseline.
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Affiliation(s)
- Carlo Visco
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy.
| | - Francesca Pregnolato
- Experimental Laboratory of Immuno-rheumatology, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy
| | - Isacco Ferrarini
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Beatrice De Marco
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Valentina Bonuomo
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Eugenio Sbisà
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Costanza Fraenza
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Andrea Bernardelli
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Ilaria Tanasi
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | | | - Mauro Krampera
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
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16
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Rigacci L, Annibali O, Kovalchuk S, Bonifacio E, Pregnolato F, Angrilli F, Vitolo U, Pozzi S, Broggi S, Luminari S, Merli F, Spina M, Bolis S, Margiotta-Casaluci G, Scalzulli R, Cox C, Mamusa AM, Santoro A, Zinzani PL, Ferrari S, Gini G, Vigliotti ML, Mulè A, Flenghi L. Nonpeghylated liposomal doxorubicin combination regimen (R-COMP) for the treatment of lymphoma patients with advanced age or cardiac comorbidity. Hematol Oncol 2020; 38:478-486. [PMID: 32542788 PMCID: PMC7689940 DOI: 10.1002/hon.2764] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/06/2020] [Accepted: 06/09/2020] [Indexed: 11/30/2022]
Abstract
Doxorubicin is the most effective single agent in the treatment of non‐Hodgkin's lymphoma (NHL). Its use is limited because of the cardiac toxicity primarily in elderly patients (pts) and in pts with history of cardiac disease. Liposomal doxorubicin has been proven to reduce cardiotoxicity. The aim of this retrospective study was the use of nonpeghylated liposomal doxorubicin (NPLD) in term of efficacy, response rate and incidence of cardiac events. We retrospectively collected the experience of 33 Hematological Italian Centers in using NPLD. Nine hundred and forty‐six consecutive pts treated with R‐COMP (doxorubicin was substituted with NPLD, Myocet) were collected. Median age was 74 years, the reasons for use of NPLD were: age (466 pts), cardiac disease (298 pts), uncontrolled hypertension (126 pts), other reasons (56 pts). According to clinicians' evaluation, 49.9% of pts would not have used standard doxorubicin for different situations (age, cardiomyopathy, previous use of doxorubicin, and uncontrolled hypertension). Overall 687 pts (72.6%) obtained a complete remission (CR). About 5% (n = 51) of subjects developed major cardiotoxic events including heart failure (N = 31), ischemic heart disease (N = 16), acute heart attack (N = 3), and acute pulmonary oedema (N = 1). After a median follow‐up of 32 months, 651 pts were alive and the overall survival (OS) was 72%. After a median observation period of 23 months disease free survival (DFS) was 58%. Either in univariate or in multivariate analysis OS and DFS were not significantly affected by age or cardiac disease. Our findings strongly support that including R‐COMP is effective and safe when the population is at high risk of cardiac events and negatively selected. Moreover, the use of this NPLD permitted that about half of our population had the opportunity to receive the best available treatment.
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Affiliation(s)
- Luigi Rigacci
- UOC Ematologia e Centro Trapianto Cellule Staminali, AO San Camillo Forlanini Roma, Roma, Italy.,SOD C Ematologia, AOU Careggi, Firenze, Italy
| | - Ombretta Annibali
- Ematologia, Trapianto Cellule Staminali, Medicina Trasfusionale, Policlinico Universitario Campus Biomedico, Roma, Italy
| | | | - Elisabetta Bonifacio
- Ematologia e Trapianto Midollo Osseo, Ospedale Santa Maria della Misericordia, Azienda Ospedaliera Perugia, Perugia, Italy
| | - Francesca Pregnolato
- Istituto Auxologico Italiano (IRCCS) Experimental Laboratory of Immunorheumatology, Cusano Milanino, Milanino, Italy
| | - Francesco Angrilli
- Unità Operativa Semplice Dipartimentale Centro Diagnosi e Terapia Linfomi, Presidio Ospedaliero, Pescara, Italy
| | - Umberto Vitolo
- SC di Ematologia, AOU Città della Salute e delle Scienze di Torino, Torino, Italy
| | - Samantha Pozzi
- Dipartimento Onco-ematologico, Policlinico di Modena, Univesrità di Modena e Reggio Emilia, Modena, Italy
| | - Serena Broggi
- Ematologia e Trapianto Midollo Osseo, Ospedale Santa Maria della Misericordia, Azienda Ospedaliera Perugia, Perugia, Italy
| | - Stefano Luminari
- Dipartimento Onco-ematologico, Policlinico di Modena, Univesrità di Modena e Reggio Emilia, Modena, Italy.,Unità Operativa di Ematologia, Arcispedale S. Maria Nuova Reggio Emilia, Emilia, Italy
| | - Francesco Merli
- Unità Operativa di Ematologia, Arcispedale S. Maria Nuova Reggio Emilia, Emilia, Italy
| | - Michele Spina
- Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Silvia Bolis
- Ematologia, Ospedale San Gerardo Monza, Monza, Italy
| | | | - Rosario Scalzulli
- Ematologia Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | | | - Angela Maria Mamusa
- Ematologia e Centro Trapianto Midollo Osseo, Ospedale Businco Cagliari, Cagliari, Italy
| | - Armando Santoro
- Department of Biomedical Sciences Milano, Ematologia, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Italy
| | | | - Samantha Ferrari
- Unità Operativa di Ematologia, Spedali Civili di Brescia, Brescia, Italy
| | - Guido Gini
- SOD Clinca Ematologica, AOU Ospedali Riuniti Ancona, Ancona, Italy
| | | | - Antonino Mulè
- UOC Ematologia e Talassemia PO Sant'Elia Caltanissetta, Caltanissetta, Italy
| | - Leonardo Flenghi
- Ematologia e Trapianto Midollo Osseo, Ospedale Santa Maria della Misericordia, Azienda Ospedaliera Perugia, Perugia, Italy
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