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Lafarge A, Chean D, Whiting L, Clere-Jehl R. Management of hematological patients requiring emergency chemotherapy in the intensive care unit. Intensive Care Med 2024; 50:849-860. [PMID: 38748265 PMCID: PMC11164740 DOI: 10.1007/s00134-024-07454-z] [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: 02/27/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
Hematological malignancies may require rapid-onset treatment because of their short doubling time, notably observed in acute leukemias and specific high-grade lymphomas. Furthermore, in targeted onco-hematological scenarios, chemotherapy is deemed necessary as an emergency measure when facing short-term, life-threatening complications associated with highly chemosensitive hematological malignancies. The risks inherent in the disease itself, or in the initiation of treatment, may then require admission to the intensive care unit (ICU) to optimize monitoring and initial management protocols. Hyperleukocytosis and leukostasis in acute leukemias, tumor lysis syndrome, and disseminated intravascular coagulation are the most frequent onco-hematological complications requiring the implementation of emergency chemotherapy in the ICU. Chemotherapy must also be started urgently in secondary hemophagocytic lymphohistiocytosis. Tumor-induced microangiopathic hemolytic anemia and plasma hyperviscosity due to malignant monoclonal gammopathy represent infrequent yet substantial indications for emergency chemotherapy. In all cases, the administration of emergency chemotherapy in the ICU requires close collaboration between intensivists and hematology specialists. In this review, we provide valuable insights that aid in the identification and treatment of patients requiring emergency chemotherapy in the ICU, offering diagnostic tools and guidance for their overall initial management.
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Affiliation(s)
- Antoine Lafarge
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.
| | - Dara Chean
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Livia Whiting
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Raphaël Clere-Jehl
- Médecine Intensive et Réanimation, Hôpital de Hautepierre, University Hospital of Strasbourg, Strasbourg, France
- Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM (French National Institute of Health and Medical Research), UMR_S1109, Centre de Recherche d'Immunologie et d'Hématologie, University of Strasbourg, Strasbourg, France
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Koo CW, Frota Lima LM, Kerper A, Lo YC. Anatomic Approach to Common and Uncommon Manifestations of Thoracic Leukemias with Radiologic-Pathologic Correlation. Radiol Cardiothorac Imaging 2023; 5:e230151. [PMID: 38166347 PMCID: PMC11163245 DOI: 10.1148/ryct.230151] [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: 06/06/2023] [Revised: 09/29/2023] [Accepted: 11/27/2023] [Indexed: 01/04/2024]
Abstract
Leukemias are hematopoietic malignancies characterized by the production of abnormal leukocytes in the bone marrow. Clinical manifestations arise from either bone marrow suppression or leukemic organ infiltration. Lymphadenopathy is the most common direct manifestation of intrathoracic leukemia. However, leukemic cells may also infiltrate the lungs, pleura, heart, bones, and soft tissues. Pulmonary complications in patients with leukemia typically include pneumonia, hemorrhage, pulmonary edema, and sequelae of leukemia treatment. However, pulmonary abnormalities can also be related directly to leukemia, including leukemic pulmonary infiltration. The direct, non-treatment-related effects of leukemia on intrathoracic structures will be the focus of this imaging essay. Given the typical anatomic approach for image interpretation, an organ-based depiction of common and less common intrathoracic findings directly caused by leukemic involvement is presented, emphasizing imaging findings with pathologic correlations. Keywords: Leukemia, Pulmonary, Thorax, Soft Tissues/Skin, Hematologic, Bone Marrow © RSNA, 2023.
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Affiliation(s)
- Chi Wan Koo
- From the Department of Radiology (C.W.K., L.M.F.L.) and Department of
Laboratory Medicine and Pathology (A.K., Y.C.L.), Mayo Clinic, 200 First St SW,
Rochester, MN 55905
| | - Livia Maria Frota Lima
- From the Department of Radiology (C.W.K., L.M.F.L.) and Department of
Laboratory Medicine and Pathology (A.K., Y.C.L.), Mayo Clinic, 200 First St SW,
Rochester, MN 55905
| | - Allison Kerper
- From the Department of Radiology (C.W.K., L.M.F.L.) and Department of
Laboratory Medicine and Pathology (A.K., Y.C.L.), Mayo Clinic, 200 First St SW,
Rochester, MN 55905
| | - Ying-Chun Lo
- From the Department of Radiology (C.W.K., L.M.F.L.) and Department of
Laboratory Medicine and Pathology (A.K., Y.C.L.), Mayo Clinic, 200 First St SW,
Rochester, MN 55905
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Cotorogea-Simion M, Pavel B, Isac S, Telecan T, Matache IM, Bobirca A, Bobirca FT, Rababoc R, Droc G. What Is Different in Acute Hematologic Malignancy-Associated ARDS? An Overview of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091215. [PMID: 36143892 PMCID: PMC9503421 DOI: 10.3390/medicina58091215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Acute hematologic malignancies are a group of heterogeneous blood diseases with a high mortality rate, mostly due to acute respiratory failure (ARF). Acute respiratory distress syndrome (ARDS) is one form of ARF which represents a challenging clinical condition. The paper aims to review current knowledge regarding the variable pathogenic mechanisms, as well as therapeutic options for ARDS in acute hematologic malignancy patients. Data collection: We provide an overview of ARDS in patients with acute hematologic malignancy, from an etiologic perspective. We searched databases such as PubMed or Google Scholar, including articles published until June 2022, using the following keywords: ARDS in hematologic malignancy, pneumonia in hematologic malignancy, drug-induced ARDS, leukostasis, pulmonary leukemic infiltration, pulmonary lysis syndrome, engraftment syndrome, diffuse alveolar hemorrhage, TRALI in hematologic malignancy, hematopoietic stem cell transplant ARDS, radiation pneumonitis. We included relevant research articles, case reports, and reviews published in the last 18 years. Results: The main causes of ARDS in acute hematologic malignancy are: pneumonia-associated ARDS, leukostasis, leukemic infiltration of the lung, pulmonary lysis syndrome, drug-induced ARDS, radiotherapy-induced ARDS, diffuse alveolar hemorrhage, peri-engraftment respiratory distress syndrome, hematopoietic stem cell transplantation-related ARDS, transfusion-related acute lung injury. Conclusions: The short-term prognosis of ARDS in acute hematologic malignancy relies on prompt diagnosis and treatment. Due to its etiological heterogeneity, precision-based strategies should be used to improve overall survival. Future studies should focus on identifying the relevance of such etiologic-based diagnostic strategies in ARDS secondary to acute hematologic malignancy.
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Affiliation(s)
- Mihail Cotorogea-Simion
- Department of Anesthesiology and Intensive Care I, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Bogdan Pavel
- Department of Physiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Sebastian Isac
- Department of Anesthesiology and Intensive Care I, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Physiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence:
| | - Teodora Telecan
- Department of Urology, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Department of Urology, Municipal Hospital, 400139 Cluj-Napoca, Romania
| | - Irina-Mihaela Matache
- Department of Physiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Anca Bobirca
- Department of Rheumatology, Dr. I. Cantacuzino Hospital, 073206 Bucharest, Romania
| | - Florin-Teodor Bobirca
- Department of General Surgery, Dr. I. Cantacuzino Hospital, 073206 Bucharest, Romania
| | - Razvan Rababoc
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Gabriela Droc
- Department of Anesthesiology and Intensive Care I, Fundeni Clinical Institute, 022328 Bucharest, Romania
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Analysis of Risk Factors of Coagulation Dysfunction and Hemorrhage in Newly Diagnosed Hyperleukocytic Acute Myeloma Leukemia. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:7828230. [PMID: 35935316 PMCID: PMC9300275 DOI: 10.1155/2022/7828230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/06/2022] [Accepted: 05/27/2022] [Indexed: 11/22/2022]
Abstract
Purpose To explore whether and why abnormal coagulation function and hemorrhage can appear in patients with hyperleukocytic acute myeloid leukemia (HAML). Method We retrospectively reviewed the charts of 724 acute myeloid leukemia (AML) patients admitted with a white blood cell count of >100 × 109/L between 2010 and 2019 in order to analyze the coagulation index of patients with HAML and explore the correlation of abnormal coagulation. Result Prothrombin time (PT) was extended in group HAML compared with group non-HAML. Respiratory failure, intracranial hemorrhage, and infection were more common in the HAML group. Among the 76 HAML patients, there were 33 patients who had ≥3 abnormal items of coagulation index, and 51.5% of them had level 2 hemorrhage which was more than level 0 hemorrhage, and the difference is statistically significant (P < 0.01). Similarly, we can discover that 40.9% of patients with 2 abnormal items had level 2 hemorrhage in contrast to 0 abnormal items. The use of hydroxyurea had a significant effect on PT and D-dimer (DD). Survival analysis by the Kaplan–Meier method showed that there were statistically significant differences in white blood cell (WBC) count>200 × 109//L and DD. Abnormal PT is associated with WBC count>200 × 109//L, and abnormal activated partial thromboplastin time (APTT) is associated with HLA-DR mutation. Infection and respiratory failure were independent influencing factors for the coagulation of patients. Conclusion DD had a marked effect on the survival rate. Infection and respiratory failure were independent influencing factors for the coagulation of patients.
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Evaluation of Non-infectious Pulmonary Complications in Hematological Malignancies on MDCT: Decoding Imaging Markers. Indian J Hematol Blood Transfus 2021; 37:669-674. [PMID: 34744350 DOI: 10.1007/s12288-021-01403-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/10/2021] [Indexed: 10/21/2022] Open
Abstract
Patients with hematological malignancies are at risk of developing of various infectious and non-infectious pulmonary complications. Common non-infectious pulmonary complications include pulmonary edema, leukostasis, diffuse alveolar haemorrhage (DAH) and differentiation syndrome. The overlapping imaging features pose diagnostic dilemma. We retrospectively analysed the CT findings in identifying differentiating imaging markers and developing an algorithm. 46 diagnosed patients of non-infectious pulmonary complications who underwent CT chest between February 2017 to March 2020 were included. The CT findings were recorded as parenchymal (GGO, consolidation, septal thickening, peribronchovascular interstitial thickening, and nodules), pleural effusion, and mediastinal lymphadenopathy. We categorized non-infectious pulmonary complications as: differentiation syndrome (Group1, n = 6), DAH (Group 2, n = 8), leukostasis (Group 3, n = 14),leukemic infiltrate (Group 4, n = 5), and pulmonary edema(Group 5, n = 13). Chi-square or Fisher exact test were used with p value < 0.05 as statistically significant.Absence of diffuse GGO in Group 4, interlobular septal thickening in Group 2 and Group 3, nodules in Group 5, and peribronchovascular interstitial thickening in Group 2 were statistically significant. Presence of interlobular septal thickening in Group 5, nodules in Group 4, and peribronchovascular interstitial thickening in Group 5 were statistically significant. Based on the results, an algorithm was developed which may suggest a possible diagnosis in an appropriate clinical scenario.
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Bewersdorf JP, Zeidan AM. Hyperleukocytosis and Leukostasis in Acute Myeloid Leukemia: Can a Better Understanding of the Underlying Molecular Pathophysiology Lead to Novel Treatments? Cells 2020; 9:cells9102310. [PMID: 33080779 PMCID: PMC7603052 DOI: 10.3390/cells9102310] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/08/2020] [Accepted: 10/15/2020] [Indexed: 12/15/2022] Open
Abstract
Up to 18% of patients with acute myeloid leukemia (AML) present with a white blood cell (WBC) count of greater than 100,000/µL, a condition that is frequently referred to as hyperleukocytosis. Hyperleukocytosis has been associated with an adverse prognosis and a higher incidence of life-threatening complications such as leukostasis, disseminated intravascular coagulation (DIC), and tumor lysis syndrome (TLS). The molecular processes underlying hyperleukocytosis have not been fully elucidated yet. However, the interactions between leukemic blasts and endothelial cells leading to leukostasis and DIC as well as the processes in the bone marrow microenvironment leading to the massive entry of leukemic blasts into the peripheral blood are becoming increasingly understood. Leukemic blasts interact with endothelial cells via cell adhesion molecules such as various members of the selectin family which are upregulated via inflammatory cytokines released by leukemic blasts. Besides their role in the development of leukostasis, cell adhesion molecules have also been implicated in leukemic stem cell survival and chemotherapy resistance and can be therapeutically targeted with specific inhibitors such as plerixafor or GMI-1271 (uproleselan). However, in the absence of approved targeted therapies supportive treatment with the uric acid lowering agents allopurinol and rasburicase as well as aggressive intravenous fluid hydration for the treatment and prophylaxis of TLS, transfusion of blood products for the management of DIC, and cytoreduction with intensive chemotherapy, leukapheresis, or hydroxyurea remain the mainstay of therapy for AML patients with hyperleukocytosis.
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Affiliation(s)
| | - Amer M. Zeidan
- Correspondence: ; Tel.: +1-203-737-7103; Fax: +1-203-785-7232
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Miyaoka C, Saraya T, Honda K, Fujiwara M, Ishii H, Takizawa H. Aggressive lung involvement in a patient with T-acute lymphoblastic leukaemia/lymphoblastic lymphoma: a tricky and rare case report. Respirol Case Rep 2020; 8:e00614. [PMID: 32642065 PMCID: PMC7330916 DOI: 10.1002/rcr2.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/14/2020] [Accepted: 06/17/2020] [Indexed: 11/08/2022] Open
Abstract
A 39-year-old man was admitted to our university hospital because of diffuse pulmonary infiltrates on chest X-ray. He had been diagnosed with T-acute lymphoblastic leukaemia/lymphoblastic lymphoma three years before and had been treated with chemotherapy and cord blood stem cell transplantation twice. Although he had neither blast cells in the peripheral blood nor leucocytosis, urgent bronchoscopy findings demonstrated blast cells invading both the alveolar spaces/alveolar septa and the vein walls. These pathological findings corresponded to ground-glass opacities and thickening of the interlobular septa on thoracic computed tomography (CT). In acute lymphoblastic leukaemia/lymphoblastic lymphoma patients presenting with infiltrates on thoracic CT, leukaemic pulmonary involvement should be considered in the differential diagnoses, even in the absence of hyperleucocytosis or blast cells in the blood, similar to pulmonary involvement in myeloid leukaemias.
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Affiliation(s)
- Chika Miyaoka
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
| | - Takeshi Saraya
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
| | - Kojiro Honda
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
| | | | - Haruyuki Ishii
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
| | - Hajime Takizawa
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
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Van de Louw A, Desai RJ, Zhu J, Claxton DF. Characteristics of early acute respiratory distress syndrome in newly diagnosed acute myeloid leukemia. Leuk Lymphoma 2018; 59:2369-2376. [PMID: 29431568 DOI: 10.1080/10428194.2018.1435874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acute respiratory complications occur frequently during the early phase of acute myeloid leukemia (AML) but information on the most severe form, acute respiratory distress syndrome (ARDS), is lacking. We retrospectively analyzed 280 patients with newly diagnosed AML in order to describe the incidence, risk factors and early mortality associated with ARDS within 15 d. Univariate and then multivariate analysis were performed. ARDS developed in 9% of patients and was associated with 64% day-30 mortality. White blood cell count on admission was an independent risk factor for ARDS (OR = 1.007, 95% CI = 1.001-1.012, p = .012) with a moderate prediction ability (AUC 0.704, p = .001). Other variables were associated with ARDS in univariate but not in multivariate analysis: body mass index (p = .06), transfusions (p = .001) and sepsis (p < .0001). Leukemia-specific complications and documented infections were the most frequent ARDS etiologies and were sometimes associated, with no clear distinctive temporal pattern.
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Affiliation(s)
- Andry Van de Louw
- a Division of Pulmonary and Critical Care Medicine , Penn State Milton S Hershey Medical Center and College of Medicine , Hershey , PA , USA
| | - Ruchi J Desai
- b Department of Internal Medicine , Penn State Milton S Hershey Medical Center and College of Medicine , Hershey , PA , USA
| | - Junjia Zhu
- c Department of Public Health Sciences , Penn State Milton S Hershey Medical Center and College of Medicine , Hershey , PA , USA
| | - David F Claxton
- d Division of Hematology and Oncology , Penn State Milton S Hershey Medical Center and College of Medicine , Hershey , PA , USA
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Jin Y, Guo S, Cui Q, Chen S, Liu X, Wei Y, Pan Y, Tang L, Huang T, Shen H, Xu G, Zuo X, Liu S, Xiao H, Chen F, Gong F, Zhou F. A hospital based retrospective study of factors influencing therapeutic leukapheresis in patients presenting with hyperleukocytic leukaemia. Sci Rep 2018; 8:294. [PMID: 29321527 PMCID: PMC5762875 DOI: 10.1038/s41598-017-17534-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/20/2017] [Indexed: 02/04/2023] Open
Abstract
Therapeutic leukapheresis is a rapid and effective method to reduce early mortality of patients with hyperleukocytic leukaemia (HLL). However, few studies on factors influencing the efficiency have been reported. In this study, 67 cases who underwent leukapheresis were retrospectively analysed and factors related to the collection efficiency of leukapheresis (CEWBC) were also evaluated. Paired t test showed that there was a significant decrease in statistics of white blood cell (WBC) counts after apheresis. The results of two independent samples nonparametric test suggested that WBC counts, platelet (PLT) counts, haematocrit (HCT), hemoglobin (HGB), serum chlorine (Cl) and globulin (GLB) before leukapheresis correlated with the CEWBC. Multiple linear regression analysis with background stepwise variable selection indicated that only WBC and HCT before leukapheresis had an influence on CEWBC significantly. Kaplan-Meier analysis and Cox regression model indicated that lymphocyte (LY) and mean corpuscular hemoglobin (MCH) pre-apheresis as independent factors significantly affected the prognostic survival of patients with HLL. Moreover, platelets and red blood cell were contaminated in the product of leukapheresis. It is an urgent problem to be solved in order to realise higher efficacy and higher purity of WBC collection to improve the survival of patients with HLL through optimising instruments.
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Affiliation(s)
- Yanxia Jin
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shishang Guo
- Key Laboratory of Artificial Micro- and Nano-Structures of Ministry of Education, School of Physics and Technology, Wuhan University, Wuhan, Hubei, China
| | - Qin Cui
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Sichao Chen
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiaoping Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yongchang Wei
- Key Laboratory of Tumor Biological Behavior of Hubei Province, Wuhan, Hubei, China.,Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yunbao Pan
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.,Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Liang Tang
- School of Mechanical Engineering, Hubei University of Technology, Wuhan, Hubei, China
| | - Tingting Huang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Hui Shen
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Guanghui Xu
- School of Mechanical Engineering, Hubei University of Technology, Wuhan, Hubei, China
| | - Xuelan Zuo
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shangqin Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Hui Xiao
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Fei Chen
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Fayun Gong
- School of Mechanical Engineering, Hubei University of Technology, Wuhan, Hubei, China.
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China. .,Key Laboratory of Tumor Biological Behavior of Hubei Province, Wuhan, Hubei, China. .,Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.
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