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Alexander M, Rogers J, Parakh S, Mitchell P, Clay TD, Kao S, Hughes BGM, Itchins M, Kong BY, Pavlakis N, Solomon BJ, John T. Lurbinectedin in small cell lung cancer: real-world experience of a multicentre national early access programme. Intern Med J 2024. [PMID: 38369719 DOI: 10.1111/imj.16348] [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: 05/07/2023] [Accepted: 01/24/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND AND AIMS Lurbinectedin is a novel oncogenic transcription inhibitor active in several cancers, including small cell lung cancer (SCLC). We aimed to describe the first Australian experience of the clinical efficacy and tolerability of lurbinectedin for the treatment of SCLC after progression on platinum-containing therapy. METHODS Multicentre real-world study of individuals with SCLC initiating lurbinectedin monotherapy (3.2 mg/m2 three-weekly) on an early access programme between May 2020 and December 2021. Key outcomes were clinical utilisation, efficacy and tolerability. Progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier method. Outcome data were collected within the AUstralian Registry and biObank of thoRacic cAncers (AURORA). RESULTS Data were analysed for 46 individuals across seven sites. Lurbinectedin was given as second- (83%, 38/46) or subsequent- (17%, 8/46) line therapy, mostly with prior chemoimmunotherapy (87%, 40/46). We report dose modifications (17%, 8/46), interruptions/delays (24%, 11/46), high-grade toxicities (28%, 13/46) and hospitalisations (54%, 25/46) during active treatment. The overall response rate was 33% and the disease control rate was 50%. Six-month OS was 44% (95% confidence interval (CI): 29.0-57.1). Twelve-month OS was 15% (95% CI: 6.5-26.8). From lurbinectedin first dose, the median PFS was 2.5 months (95% CI: 1.8-2.9) and OS was 4.5 months (95% CI: 3.5-7.2). From SCLC diagnosis, the median OS was 12.9 months (95% CI: 11.0-17.2). Individuals with a longer chemotherapy-free interval prior to lurbinectedin had longer PFS and OS. CONCLUSION This real-world national experience of lurbinectedin post-platinum chemotherapy and immunotherapy for individuals with SCLC was similar to that reported in clinical trials.
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Affiliation(s)
- Marliese Alexander
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Rogers
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sagun Parakh
- Austin Hospital, Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia
- School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia
| | - Paul Mitchell
- Austin Hospital, Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia
- Division of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy D Clay
- Saint John of God Subiaco Hospital, Perth, Western Australia, Australia
- Icon Cancer Care Midland, Perth, Western Australia, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Steven Kao
- Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brett G M Hughes
- The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Malinda Itchins
- Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Benjamin Y Kong
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Nick Pavlakis
- Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Benjamin J Solomon
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas John
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
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Khoury R, Assi T, Ibrahim R, Ibrahim T, Verret B, Henon C, Bahleda R, Le Cesne A. A Comprehensive Review on the Role of Lurbinectedin in Soft Tissue Sarcomas. Curr Treat Options Oncol 2024; 25:176-190. [PMID: 38324075 DOI: 10.1007/s11864-024-01178-4] [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] [Accepted: 01/08/2024] [Indexed: 02/08/2024]
Abstract
OPINION STATEMENT Soft tissue sarcoma (STS), a substantial group of aggressive and rare tumors with tissue heterogeneity, is infrequently represented in clinical trials with an urgent necessity for newer treatment options. Lurbinectedin, an analog of trabectedin, is currently approved, in various countries, as a single agent, for the treatment of patients with relapsed small cell lung cancer (SCLC). However, preclinical and phase I and phase II trials have demonstrated the efficacy of lurbinectedin in different tumor types, including STS. The better understanding of the pathophysiology and evolution of STS as well as the mechanism of action of lurbinectedin in addition to the available data regarding the activity of this drug in this subset of patients will pave the way to newer therapeutic options and strategies.
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Affiliation(s)
- Rita Khoury
- Division of International Patients Care, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
| | - Tarek Assi
- Division of International Patients Care, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France.
- Sarcoma Unit, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France.
| | - Rebecca Ibrahim
- Division of International Patients Care, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
| | - Tony Ibrahim
- Division of International Patients Care, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
| | - Benjamin Verret
- Sarcoma Unit, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
| | - Clemence Henon
- Sarcoma Unit, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
| | - Ratislav Bahleda
- Sarcoma Unit, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
| | - Axel Le Cesne
- Division of International Patients Care, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
- Sarcoma Unit, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
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Povo-Retana A, Landauro-Vera R, Alvarez-Lucena C, Cascante M, Boscá L. Trabectedin and Lurbinectedin Modulate the Interplay between Cells in the Tumour Microenvironment-Progresses in Their Use in Combined Cancer Therapy. Molecules 2024; 29:331. [PMID: 38257245 PMCID: PMC10820391 DOI: 10.3390/molecules29020331] [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: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Trabectedin (TRB) and Lurbinectedin (LUR) are alkaloid compounds originally isolated from Ecteinascidia turbinata with proven antitumoral activity. Both molecules are structural analogues that differ on the tetrahydroisoquinoline moiety of the C subunit in TRB, which is replaced by a tetrahydro-β-carboline in LUR. TRB is indicated for patients with relapsed ovarian cancer in combination with pegylated liposomal doxorubicin, as well as for advanced soft tissue sarcoma in adults in monotherapy. LUR was approved by the FDA in 2020 to treat metastatic small cell lung cancer. Herein, we systematically summarise the origin and structure of TRB and LUR, as well as the molecular mechanisms that they trigger to induce cell death in tumoral cells and supporting stroma cells of the tumoral microenvironment, and how these compounds regulate immune cell function and fate. Finally, the novel therapeutic venues that are currently under exploration, in combination with a plethora of different immunotherapeutic strategies or specific molecular-targeted inhibitors, are reviewed, with particular emphasis on the usage of immune checkpoint inhibitors, or other bioactive molecules that have shown synergistic effects in terms of tumour regression and ablation. These approaches intend to tackle the complexity of managing cancer patients in the context of precision medicine and the application of tailor-made strategies aiming at the reduction of undesired side effects.
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Affiliation(s)
- Adrián Povo-Retana
- Instituto de Investigaciones Biomédicas Alberto Sols-Morreale (CSIC-UAM), Arturo Duperier 4, 28029 Madrid, Spain; (R.L.-V.); (C.A.-L.)
| | - Rodrigo Landauro-Vera
- Instituto de Investigaciones Biomédicas Alberto Sols-Morreale (CSIC-UAM), Arturo Duperier 4, 28029 Madrid, Spain; (R.L.-V.); (C.A.-L.)
| | - Carlota Alvarez-Lucena
- Instituto de Investigaciones Biomédicas Alberto Sols-Morreale (CSIC-UAM), Arturo Duperier 4, 28029 Madrid, Spain; (R.L.-V.); (C.A.-L.)
| | - Marta Cascante
- Department of Biochemistry and Molecular Biomedicine-Institute of Biomedicine (IBUB), Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Spain;
- Department of Material Science and Physical Chemistry, Research Institute of Theoretical and Computational Chemistry (IQTCUB), University of Barcelona, 08028 Barcelona, Spain
| | - Lisardo Boscá
- Instituto de Investigaciones Biomédicas Alberto Sols-Morreale (CSIC-UAM), Arturo Duperier 4, 28029 Madrid, Spain; (R.L.-V.); (C.A.-L.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Institute of Health Carlos III (ISCIII), 28029 Madrid, Spain
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Canova S, Trevisan B, Abbate MI, Colonese F, Sala L, Baggi A, Bianchi SP, D'Agostino A, Cortinovis DL. Novel Therapeutic Options for Small Cell Lung Cancer. Curr Oncol Rep 2023; 25:1277-1294. [PMID: 37870696 PMCID: PMC10640463 DOI: 10.1007/s11912-023-01465-7] [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] [Accepted: 09/19/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to focus on the recent advances in the molecular knowledge of small cell lung cancer (SCLC) and potential promising new treatment strategies, like targeting the DNA damage pathway, epigenetics, angiogenesis, and oncogenic drivers. RECENT FINDINGS In the last few years, the addition of immunotherapy to chemotherapy has led to significant improvements in clinical outcomes in this complex neoplasia. Nevertheless, the prognosis remains dismal. Recently, numerous genomic alterations have been identified, and they may be useful to classify SCLC into different molecular subtypes (SCLC-A, SCLC-I, SCLC-Y, SCLC-P). SCLC accounts for 10-20% of all lung cancers, most patients have an extensive disease at the diagnosis, and it is characterized by poor prognosis. Despite the progresses in the knowledge of the disease, efficacious targeted treatments are still lacking. In the near future, the molecular characterisation of SCLC will be fundamental to find more effective treatment strategies.
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Affiliation(s)
- Stefania Canova
- SC Medical Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Benedetta Trevisan
- SC Medical Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Medical-Surgical Specialties, University of Brescia, Radiological Sciences and Public Health, Brescia, Italy
| | - Maria Ida Abbate
- SC Medical Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Francesca Colonese
- SC Medical Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Luca Sala
- SC Medical Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Alice Baggi
- SC Medical Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Department of Medical-Surgical Specialties, University of Brescia, Radiological Sciences and Public Health, Brescia, Italy
| | - Sofia Paola Bianchi
- Radiation Oncology Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Anna D'Agostino
- SC Medical Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Diego Luigi Cortinovis
- SC Medical Oncology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy.
- Medicine and Surgery Department, University of Milano Bicocca, Milan, Italy.
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Tummala T, Sevilla Uruchurtu AS, Cruz ADL, Huntington KE, George A, Liguori NR, Zhang L, Zhou L, Abbas AE, Azzoli CG, El-Deiry WS. Preclinical Synergistic Combination Therapy of Lurbinectedin with Irinotecan and 5-Fluorouracil in Pancreatic Cancer. Curr Oncol 2023; 30:9611-9626. [PMID: 37999116 PMCID: PMC10670398 DOI: 10.3390/curroncol30110696] [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: 09/16/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
Pancreatic cancer is a devastating disease with a poor prognosis. Novel chemotherapeutics in pancreatic cancer have shown limited success, illustrating the urgent need for new treatments. Lurbinectedin (PM01183; LY-01017) received FDA approval in 2020 for metastatic small cell lung cancer on or after platinum-based chemotherapy and is currently undergoing clinical trials in a variety of tumor types. Lurbinectedin stalls and degrades RNA Polymerase II and introduces breaks in DNA, causing subsequent apoptosis. We now demonstrate lurbinectedin's highly efficient killing of human-derived pancreatic tumor cell lines PANC-1, BxPC-3, and HPAF-II as a single agent. We further demonstrate that a combination of lurbinectedin and irinotecan, a topoisomerase I inhibitor with FDA approval for advanced pancreatic cancer, results in the synergistic killing of pancreatic tumor cells. Western blot analysis of combination therapy indicates an upregulation of γH2AX, a DNA damage marker, and the Chk1/ATR pathway, which is involved in replicative stress and DNA damage response. We further demonstrate that the triple combination between lurbinectedin, irinotecan, and 5-fluorouracil (5-FU) results in a highly efficient killing of tumor cells. Our results are developing insights regarding molecular mechanisms underlying the therapeutic efficacy of a novel combination drug treatment for pancreatic cancer.
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Affiliation(s)
- Tej Tummala
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA; (T.T.); (A.S.S.U.); (A.D.L.C.); (K.E.H.); (A.G.); (N.R.L.); (L.Z.); (L.Z.)
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
| | - Ashley Sanchez Sevilla Uruchurtu
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA; (T.T.); (A.S.S.U.); (A.D.L.C.); (K.E.H.); (A.G.); (N.R.L.); (L.Z.); (L.Z.)
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
| | - Arielle De La Cruz
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA; (T.T.); (A.S.S.U.); (A.D.L.C.); (K.E.H.); (A.G.); (N.R.L.); (L.Z.); (L.Z.)
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
| | - Kelsey E. Huntington
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA; (T.T.); (A.S.S.U.); (A.D.L.C.); (K.E.H.); (A.G.); (N.R.L.); (L.Z.); (L.Z.)
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
| | - Andrew George
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA; (T.T.); (A.S.S.U.); (A.D.L.C.); (K.E.H.); (A.G.); (N.R.L.); (L.Z.); (L.Z.)
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
| | - Nicholas R. Liguori
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA; (T.T.); (A.S.S.U.); (A.D.L.C.); (K.E.H.); (A.G.); (N.R.L.); (L.Z.); (L.Z.)
| | - Leiqing Zhang
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA; (T.T.); (A.S.S.U.); (A.D.L.C.); (K.E.H.); (A.G.); (N.R.L.); (L.Z.); (L.Z.)
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA
| | - Lanlan Zhou
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA; (T.T.); (A.S.S.U.); (A.D.L.C.); (K.E.H.); (A.G.); (N.R.L.); (L.Z.); (L.Z.)
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA
- Joint Program in Cancer Biology, Lifespan Health System and Brown University, Providence, RI 02903, USA
| | - Abbas E. Abbas
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA
- Joint Program in Cancer Biology, Lifespan Health System and Brown University, Providence, RI 02903, USA
- Department of Surgery, Brown University, Providence, RI 02912, USA
| | - Christopher G. Azzoli
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
- Joint Program in Cancer Biology, Lifespan Health System and Brown University, Providence, RI 02903, USA
- Hematology/Oncology Division, Department of Medicine, Lifespan Health System and Brown University, Providence, RI 02903, USA
| | - Wafik S. El-Deiry
- Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA; (T.T.); (A.S.S.U.); (A.D.L.C.); (K.E.H.); (A.G.); (N.R.L.); (L.Z.); (L.Z.)
- Legorreta Cancer Center at Brown University, Providence, RI 02912, USA; (A.E.A.); (C.G.A.)
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA
- Joint Program in Cancer Biology, Lifespan Health System and Brown University, Providence, RI 02903, USA
- Hematology/Oncology Division, Department of Medicine, Lifespan Health System and Brown University, Providence, RI 02903, USA
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Ovejero-Sánchez M, González-Sarmiento R, Herrero AB. DNA Damage Response Alterations in Ovarian Cancer: From Molecular Mechanisms to Therapeutic Opportunities. Cancers (Basel) 2023; 15:448. [PMID: 36672401 PMCID: PMC9856346 DOI: 10.3390/cancers15020448] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 01/12/2023] Open
Abstract
The DNA damage response (DDR), a set of signaling pathways for DNA damage detection and repair, maintains genomic stability when cells are exposed to endogenous or exogenous DNA-damaging agents. Alterations in these pathways are strongly associated with cancer development, including ovarian cancer (OC), the most lethal gynecologic malignancy. In OC, failures in the DDR have been related not only to the onset but also to progression and chemoresistance. It is known that approximately half of the most frequent subtype, high-grade serous carcinoma (HGSC), exhibit defects in DNA double-strand break (DSB) repair by homologous recombination (HR), and current evidence indicates that probably all HGSCs harbor a defect in at least one DDR pathway. These defects are not restricted to HGSCs; mutations in ARID1A, which are present in 30% of endometrioid OCs and 50% of clear cell (CC) carcinomas, have also been found to confer deficiencies in DNA repair. Moreover, DDR alterations have been described in a variable percentage of the different OC subtypes. Here, we overview the main DNA repair pathways involved in the maintenance of genome stability and their deregulation in OC. We also recapitulate the preclinical and clinical data supporting the potential of targeting the DDR to fight the disease.
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Affiliation(s)
- María Ovejero-Sánchez
- Institute of Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Molecular Medicine Unit, Department of Medicine, University of Salamanca, 37007 Salamanca, Spain
- Institute of Molecular and Cellular Biology of Cancer (IBMCC), University of Salamanca-Spanish National Research Council, 37007 Salamanca, Spain
| | - Rogelio González-Sarmiento
- Institute of Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Molecular Medicine Unit, Department of Medicine, University of Salamanca, 37007 Salamanca, Spain
- Institute of Molecular and Cellular Biology of Cancer (IBMCC), University of Salamanca-Spanish National Research Council, 37007 Salamanca, Spain
| | - Ana Belén Herrero
- Institute of Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Molecular Medicine Unit, Department of Medicine, University of Salamanca, 37007 Salamanca, Spain
- Institute of Molecular and Cellular Biology of Cancer (IBMCC), University of Salamanca-Spanish National Research Council, 37007 Salamanca, Spain
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