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Gill H, Yim R, Pang HH, Lee P, Chan TSY, Hwang YY, Leung GMK, Ip HW, Leung RYY, Yip SF, Kho B, Lee HKK, Mak V, Chan CC, Lau JSM, Lau CK, Lin SY, Wong RSM, Li W, Ma ESK, Li J, Panagiotou G, Sim JPY, Lie AKW, Kwong YL. Clofarabine, cytarabine, and mitoxantrone in refractory/relapsed acute myeloid leukemia: High response rates and effective bridge to allogeneic hematopoietic stem cell transplantation. Cancer Med 2020; 9:3371-3382. [PMID: 32187883 PMCID: PMC7221314 DOI: 10.1002/cam4.2865] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/23/2019] [Accepted: 12/26/2019] [Indexed: 12/15/2022] Open
Abstract
Clofarabine is active in refractory/relapsed acute myeloid leukemia (AML). In this phase 2 study, we treated 18‐ to 65‐year‐old AML patients refractory to first‐line 3 + 7 daunorubicin/cytarabine induction or relapsing after 3 + 7 induction and high‐dose cytarabine consolidation, with clofarabine (30 mg/m2/d, Days 1‐5), cytarabine (750 mg/m2/d, Days 1‐5), and mitoxantrone (12 mg/m2/d, Days 3‐5) (CLAM). Patients achieving remission received up to two consolidation cycles of 50% CLAM, with eligible cases bridged to allogeneic hematopoietic stem cell transplantation (allo‐HSCT). The mutational profile of a 69‐gene panel was evaluated. Twenty‐six men and 26 women at a median age of 46 (22‐65) years were treated. The overall response rate after the first cycle of CLAM was 90.4% (complete remission, CR: 69.2%; CR with incomplete hematologic recovery, CRi: 21.2%). Twenty‐two CR/CRi patients underwent allo‐HSCT. The 2‐year overall survival (OS), relapse‐free survival (RFS), and event‐free survival (EFS) were 65.8%, 45.7%, and 40.2%, respectively. Multivariate analyses showed that superior OS was associated with CR after CLAM (P = .005) and allo‐HSCT (P = .005), and superior RFS and EFS were associated with allo‐HSCT (P < .001). Remarkably, CR after CLAM and allo‐HSCT resulted in 2‐year OS of 84.3% and 90%, respectively. Karyotypic aberrations and genetic mutations did not influence responses or survivals. Grade 3/4 neutropenia/thrombocytopenia and grade 3 febrile neutropenia occurred in all cases. Other nonhematologic toxicities were mild and uncommon. There was no treatment‐related mortality and the performance of allo‐HSCT was not compromised. Clofarabine, cytarabine, and mitoxantrone was highly effective and safe in refractory/relapsed AML. This study was registered at ClinicalTrials.gov (NCT02686593).
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Affiliation(s)
- Harinder Gill
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Rita Yim
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Herbert H Pang
- School of Public Health, The University of Hong Kong, Hong Kong SAR, China
| | - Paul Lee
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Thomas S Y Chan
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yu-Yan Hwang
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Garret M K Leung
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ho-Wan Ip
- Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
| | - Rock Y Y Leung
- Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
| | - Sze-Fai Yip
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
| | - Bonnie Kho
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Harold K K Lee
- Department of Medicine, Princess Margaret Hospital, Hong Kong SAR, China
| | - Vivien Mak
- Department of Medicine, Princess Margaret Hospital, Hong Kong SAR, China
| | - Chi-Chung Chan
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - June S M Lau
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Chi-Kuen Lau
- Department of Medicine, Tseung Kwan O Hospital, Hong Kong SAR, China
| | - Shek-Yin Lin
- Department of Medicine, United Christian Hospital, Hong Kong SAR, China
| | - Raymond S M Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Wa Li
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China
| | - Edmond S K Ma
- Department of Pathology, Hong Kong Sanatorium and Hospital, Hong Kong SAR, China
| | - Jun Li
- Department of Infectious Diseases and Public Health, The City University of Hong Kong, Hong Kong SAR, China.,School of Biological Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Gianni Panagiotou
- School of Biological Sciences, The University of Hong Kong, Hong Kong SAR, China.,Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.,Department of Systems Biology and Bioinformatics, Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute (HKI), Jena, Germany
| | - Joycelyn P Y Sim
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Albert K W Lie
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yok-Lam Kwong
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Megías-Vericat JE, Martínez-Cuadrón D, Sanz MÁ, Montesinos P. Salvage regimens using conventional chemotherapy agents for relapsed/refractory adult AML patients: a systematic literature review. Ann Hematol 2018; 97:1115-1153. [DOI: 10.1007/s00277-018-3304-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/12/2018] [Indexed: 12/26/2022]
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Fathi AT, Chen YB. Treatment of relapse of acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation. Curr Hematol Malig Rep 2015; 9:186-92. [PMID: 24643311 DOI: 10.1007/s11899-014-0209-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Disease relapse remains a major cause of mortality for patients with acute myeloid leukemia (AML) undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Historically, patients who experience disease relapse after HSCT have a dismal prognosis with very few long-term survivors. There is no standard treatment for patients in this situation given the variability in patient characteristics, disease biology, complications such as graft-vs.-host disease (GVHD) and infections, donor availability, and patient choice. Here, we discuss the current options for treatment of relapsed AML after HSCT including conventional chemotherapy, novel agents, donor leukocyte infusion, second allogeneic HSCT, and emerging therapies.
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Affiliation(s)
- Amir T Fathi
- Center for Leukemia, Massachusetts General Hospital, Zero Emerson Place, Suite 118, Boston, MA, 02114, USA,
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5
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Roberts DA, Wadleigh M, McDonnell AM, DeAngelo DJ, Stone RM, Steensma DP. Low efficacy and high mortality associated with clofarabine treatment of relapsed/refractory acute myeloid leukemia and myelodysplastic syndromes. Leuk Res 2014; 39:204-10. [PMID: 25554239 DOI: 10.1016/j.leukres.2014.11.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 11/26/2014] [Accepted: 11/29/2014] [Indexed: 10/24/2022]
Abstract
Clofarabine, a second-generation nucleoside analog, has clinical activity in relapsed or refractory acute myelogenous leukemia (AML) and higher-risk myelodysplastic syndromes (MDS). However, there are few data evaluating performance of clofarabine in populations of patients not enrolled in clinical trials. We reviewed outcomes for 84 patients treated with clofarabine for relapsed or refractory AML or MDS, either with clofarabine as monotherapy (n=19) or in combination with cytarabine (n=65). Using International Working Group (IWG) response criteria, the overall response rate (ORR) of all treated patients was 21%, with a complete response rate with either complete or incomplete hematopoietic recovery (CRR=CR+CRi) of 14%. For combination therapy, ORR was 22% with CRR of 18%, and monotherapy patients had an ORR of 21% with CRR of 11%. Although limited by small numbers, subgroup analysis did not reveal variation in response rates when comparing different risk factors. The 30-day mortality was 21% and median survival was 3 months; a subset of 12 patients who were able to go to transplant had an 18-month median survival. Clofarabine's efficacy in a "real-world" setting appears to be less than has been reported in clinical trials, and treatment is associated with a high early mortality rate.
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Affiliation(s)
- Daniel A Roberts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Martha Wadleigh
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anne M McDonnell
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel J DeAngelo
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Richard M Stone
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David P Steensma
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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6
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Fozza C. The role of Clofarabine in the treatment of adults with acute myeloid leukemia. Crit Rev Oncol Hematol 2014; 93:237-45. [PMID: 25457773 DOI: 10.1016/j.critrevonc.2014.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 09/08/2014] [Accepted: 10/14/2014] [Indexed: 10/24/2022] Open
Abstract
The therapeutic scenario available for adult patients with acute myeloid leukemia (AML) has shown only partial progresses over the last few years. This is especially true for refractory and relapsed AML whose outcome is still extremely disappointing. In this context Clofarabine has offered new promising perspectives within first and second line protocols. This review will firstly describe the initial development in monotherapy, considering then the different potential combination strategies which include both polichemotherapeutic regimens and less conventional approaches with new generation drugs. The potential use of Clofarabine as induction treatment for patients candidate to stem cell transplantation and within conditioning regimens will be finally evaluated.
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Affiliation(s)
- Claudio Fozza
- Hematology, Department of Biomedical Sciences, University of Sassari, Viale San Pietro 12, 07100 Sassari, Italy.
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Aleem A, Anjum F, Algahtani F, Iqbal Z, Alsaleh K, Almomen A. Clofarabine in the treatment of elderly patients with acute myeloid leukemia. Asian Pac J Cancer Prev 2014; 14:1089-92. [PMID: 23621192 DOI: 10.7314/apjcp.2013.14.2.1089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elderly patients with acute myeloid leukemia (AML) have a poor outcome because of co- morbidities, poor tolerance to intensive chemotherapy and inherently more resistant disease. Clofarabine is a second generation nucleoside analogue which has shown promising activity in elderly patients with AML. This study was conducted to review the outcome of treatment with clofarabine in a group of such patients. METHODS The records of 5 elderly patients who were diagnosed to have AML and treated with clofarabine over a 12 month period were reviewed retrospectively. RESULTS There were 2 female and 3 male patients with a median age of 68 years (range 65-82). At the time of treatment, 2 patients had newly diagnosed AML not considered suitable for intensive therapy, while 3 patients had partial or no response to conventional chemotherapy. The overall response rate was 100%, all patients achieving a complete remission. Induction and consolidation were well tolerated. All patients developed neutropenia with a median duration of 20 days (range 17-42). One patient developed hand and foot syndrome and a generalized rash but recovered. There was no mortality and all patients remained in remission after a median follow-up of 5.2 months (Range 3-10). CONCLUSION Clofarabine (alone or in combination) is active in elderly AML patients with an acceptable safety profile and should be considered a potential option in this group.
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Affiliation(s)
- Aamer Aleem
- Department of Medicine, Division of Hematology /Oncology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
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Clofarabine in combination with a standard remission induction regimen (cytosine arabinoside and idarubicin) in patients with previously untreated intermediate and bad-risk acute myelogenous leukemia (AML) or high-risk myelodysplastic syndrome (HR-MDS): phase I results of an ongoing phase I/II study of the leukemia groups of EORTC and GIMEMA (EORTC GIMEMA 06061/AML-14A trial). Ann Hematol 2014; 93:965-75. [PMID: 24682421 DOI: 10.1007/s00277-014-2056-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
Abstract
This study aims to determine the maximum tolerated dose (MTD) of clofarabine combined with the EORTC-GIMEMA 3 + 10 induction regimen (idarubicin + cytosine arabinoside) in adults with untreated acute myelogenous leukemia or high-risk myelodysplastic syndrome. In this phase I trial, 25 patients (median age 56 years) received 5 days of clofarabine as 1-h infusion (arm A) or push injection (arm B) at the dose level of 5 × 10 or 5 × 15 mg/m(2)/day in an algorithmic dose escalation 3 + 3 design. A consolidation course (intermediate dose cytosine arabinoside, idarubicin) was planned for patients in complete remission (CR). Primary endpoint was safety and tolerance as measured by dose limiting toxicity (DLT); secondary endpoints were response rate, other grade III/IV toxicities, and hematological recovery after induction and consolidation. Five DLTs were observed (in arm A: one DLT at 10 mg/m(2)/day, three at 15 mg/m(2)/day; in arm B: one DLT at 15 mg/m(2)/day). Three patients receiving 15 mg/m(2)/day were withdrawn due to adverse events not classified as DLT. Prolonged hypoplasia was observed in five patients. CR + complete remission with incomplete recovery were achieved in 21 patients (11/12 (92 %) receiving clofarabine 10 mg/m(2)/day; 10/13 (77 %) receiving clofarabine 15 mg/m(2)/day). Clofarabine, 5 × 10 mg/m(2)/day, resulted in one DLT and no early treatment withdrawals. MTD of clofarabine combined with cytosine arabinoside and idarubicin is 5 × 10 mg/m(2)/day.
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Breakthrough invasive fungal diseases during echinocandin treatment in high-risk hospitalized hematologic patients. Ann Hematol 2013; 93:493-8. [DOI: 10.1007/s00277-013-1882-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 08/06/2013] [Indexed: 10/26/2022]
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10
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Etoposide in combination with low-dose CAG (cytarabine, aclarubicin, G-CSF) for the treatment of relapsed or refractory acute myeloid leukemia: A multicenter, randomized control trial in southwest China. Leuk Res 2013; 37:657-64. [DOI: 10.1016/j.leukres.2013.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 03/03/2013] [Accepted: 03/04/2013] [Indexed: 11/19/2022]
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Leung AY, Tse E, Hwang YY, Chan TS, Gill H, Chim CS, Lie AK, Kwong YL. Primary treatment of leukemia relapses after allogeneic hematopoietic stem cell transplantation with reduced-intensity conditioning second transplantation from the original donor. Am J Hematol 2013; 88:485-91. [PMID: 23512868 DOI: 10.1002/ajh.23439] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 03/11/2013] [Accepted: 03/13/2013] [Indexed: 01/25/2023]
Abstract
Acute leukemia relapsing after allogeneic hematopoietic stem cell transplantation (HSCT) has dismal outcome. Consecutive consenting patients (acute myeloid leukemia: N = 71; acute lymphoblastic leukemia: N = 37), at a median age of 37 (16-57) years, who had relapsed 7.9 (1.3-132) months post-HSCT, were treated with three cytarabine-based intensive regimens as reduced-intensity conditioning (RIC), followed by infusion of mobilized HSC from the original donors. There were four treatment-related mortalities (TRMs). Of 104 evaluable cases, 72 patients (67%) achieved complete remission (CR)/CR with incomplete hematologic recovery (CRi). The median overall survival (OS) of the entire cohort was 11.6 months. The OS of patients achieving CR/CRi after the first RIC/HSCT was 18.8 months, as compared with 3.9 months for those not (P < 0.01). For 32 patients with nonremission, 11 received a repeat RIC-HSCT, leading to CR/CRi in three cases. Therefore, 75/108 (69%) of patients achieved CR/CRi after one or two courses of RIC-HSCT. Among CR/CRi patients, 48 cases relapsed again after 6.1 (1.0-64.4) months. Thirty cases received a repeat RIC-HSCT, leading to CR/CRi in 22 patients. Multivariate analyses showed a significant impact of remission duration after initial HSCT (P = 0.026) and the presence of acute graft-versus-host disease after RIC-HSCT (P = 0.011) on CR/CRi. RIC-HSCT as primary treatment for acute leukemic relapses post-HSCT induced a high CR rate with low TRM. Optimal postremission treatment remains to be defined.
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Affiliation(s)
| | - Eric Tse
- Department of Medicine; Queen Mary Hospital; Hong Kong
| | - Yu-Yan Hwang
- Department of Medicine; Queen Mary Hospital; Hong Kong
| | | | - Harinder Gill
- Department of Medicine; Queen Mary Hospital; Hong Kong
| | | | | | - Yok-Lam Kwong
- Department of Medicine; Queen Mary Hospital; Hong Kong
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Hwang YY, Trendell-Smith NJ, Yeung CK, Kwong YL. Fatal palmar-plantar erythrodysesthesia after clofarabine and cytarabine chemotherapy. Acta Haematol 2012; 128:151-3. [PMID: 22890199 DOI: 10.1159/000338828] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 04/12/2012] [Indexed: 11/19/2022]
Affiliation(s)
- Yu-Yan Hwang
- Department of Medicine, Queen Mary Hospital, Hong Kong, SAR, China
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Zeidan AM, Ricklis RM, Carraway HE, Yun HD, Greer JM, Smith BD, Levis MJ, McDevitt MA, Pratz KW, Showel MM, Gladstone DE, Gore SD, Karp JE. Phase 1 dose-escalation trial of clofarabine followed by escalating dose of fractionated cyclophosphamide in adults with relapsed or refractory acute leukaemias. Br J Haematol 2012; 158:198-207. [PMID: 22594769 DOI: 10.1111/j.1365-2141.2012.09142.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 03/23/2012] [Indexed: 11/24/2022]
Abstract
The prognosis of patients with relapsed and refractory acute leukaemia (RRAL) is very poor. Forty patients with RRAL were enroled [28 acute myeloid leukaemia (AML), 12 acute lymphoblastic leukaemia (ALL)] in this Phase 1 dose-escalation trial of daily-infused clofarabine (CLO) followed by cyclophosphamide (CY) for four consecutive days (CLO-CYx4). The median age was 48·5 years. The median number of prior regimens was 2 (range 1-5), and 6/40 patients (15%) had prior allogeneic haematopoietic stem cell transplant. 28/40 patients (70%) had adverse genetic features. 6/40 patients (15%) died within 60 d of induction (two infections, four progressive disease). The average time to neutrophil recovery (absolute neutrophil count ≥0·5 × 10(9) /l was 34 d, (range, 17-78). The overall response rate (ORR) was 33% (13/40), with seven complete remissions (18%), four complete remissions with incomplete recovery of blood counts (10%), and two partial remissions (5%). ORR was 25% (7/28), and 50% (6/12), for AML and ALL respectively. Notably, the clinical responses were independent of dose level. 7/17 patients (41%) exhibited CLO-mediated enhancement of CY-induced DNA, which was associated with, but not necessary for, improved clinical outcomes. In summary, the CLO-CYx4 regimen was well tolerated and had activity in patients with RRAL, especially relapsed ALL. Therefore, CLO-CYx4 can be considered a salvage therapy for adults with RRALs, and warrants further investigations.
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Affiliation(s)
- Amer M Zeidan
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Rebecca M Ricklis
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Hetty E Carraway
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Hyun D Yun
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Jacqueline M Greer
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - B Douglas Smith
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Mark J Levis
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Michael A McDevitt
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Keith W Pratz
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Margaret M Showel
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Douglas E Gladstone
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Steven D Gore
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Judith E Karp
- Division of Hematologic Malignancies, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
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