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Brooks TR, Caimi PF. A paradox of choice: Sequencing therapy in relapsed/refractory diffuse large B-cell lymphoma. Blood Rev 2024; 63:101140. [PMID: 37949705 DOI: 10.1016/j.blre.2023.101140] [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: 04/18/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
The available treatments for relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) have experienced a dramatic change since 2017. Incremental advances in basic and translational science over several decades have led to innovations in immune-oncology. These innovations have culminated in eight separate approvals by the US Food and Drug Administration for the treatment of patients with R/R DLBCL over the last 10 years. High-dose therapy and autologous stem cell transplant (HDT-ASCT) remains the standard of care for transplant-eligible patients who relapse after an initial remission. For transplant-ineligible patients or for those who relapse following HDT-ASCT, multiple options exist. Monoclonal antibodies targeting CD19, antibody-drug conjugates, bispecific antibodies, immune effector cell products, and other agents with novel mechanisms of action are now available for patients with R/R DLBCL. There is increasing use of chimeric antigen receptor (CAR) T-cells as second-line therapy for patients with early relapse of DLBCL or those who are refractory to initial chemoimmunotherapy. The clinical benefits of these strategies vary and are influenced by patient and disease characteristics, as well as the type of prior therapy administered. Therefore, there are multiple clinical scenarios that clinicians might encounter when treating R/R DLBCL. An optimal sequence of drugs has not been established, and there is no evidence-based consensus on how to best order these agents. This abundance of choices introduces a paradox: proliferating treatment options are initially a boon to patients and providers, but as choices grow further they no longer liberate. Rather, more choices make the management of R/R DLBCL more challenging due to lack of direct comparisons among agents and a desire to maximize patient outcomes. Here, we provide a review of recently-approved second- and subsequent-line agents, summarize real-world data detailing the use of these medicines, and provide a framework for sequencing therapy in R/R DLBCL.
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Affiliation(s)
- Taylor R Brooks
- Department of Hematology and Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, OH, United States of America
| | - Paolo F Caimi
- Department of Hematology and Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, OH, United States of America; Case Comprehensive Cancer Center, Cleveland, OH, United States of America.
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2
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Wudhikarn K, Johnson BM, Inwards DJ, Porrata LF, Micallef IN, Ansell SM, Hogan WJ, Paludo J, Villasboas JC, Johnston PB. Outcomes of Older Adults with Non-Hodgkin Lymphoma Undergoing Autologous Stem Cell Transplantation: A Mayo Clinic Cohort Analysis. Transplant Cell Ther 2023; 29:176.e1-176.e8. [PMID: 36563788 DOI: 10.1016/j.jtct.2022.12.011] [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: 10/26/2022] [Revised: 12/14/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022]
Abstract
Autologous stem cell transplantation (ASCT) is an important treatment that can offer a cure for patients with lymphoma. However, advanced age is an important factor that determines eligibility and outcomes after ASCT. Over the past decade, attributed to improved supportive care, ASCT for older patients has become more feasible. In this study, we report the single-center outcomes of older patients with lymphoma undergoing ASCT at Mayo Clinic Rochester to highlight its interval improvement over time and to help redefine the implications of ASCT in the chimeric antigen receptor T cell therapy era. This single-center retrospective study evaluated the characteristics and outcomes of older patients with lymphoma who underwent ASCT between 2000 and 2021. We report various relevant transplantation-related outcomes, including progression-free survival, overall survival (OS), relapse incidence, and nonrelapse mortality (NRM) in older patients with various lymphoma histologic subtypes. The main outcome was NRM, defined as the time from ASCT to non-lymphoma-related death, with relapse as a competing event. Of 492 patients age ≥65 years were analyzed. The median age at ASCT was 68.8 years. The most common indication for ASCT was diffuse large B cell lymphoma, accounting for 59.3% of cases. In multivariate analyses, patients undergoing ASCT in 2009 to 2021, an Eastern Cooperative Oncology Group Performance Status of 0, and low Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI) (0 to 3) had a significantly lower NRM. Factors associated with OS included age, lactate dehydrogenase level, and HCT-CI. The 1-year NRM in older patients was low at 6.0%, in concordance with previous reports. Age should not be the sole factor determining a patient's ASCT eligibility. With the proper patient selection, ASCT remains a reasonable option for older patients with lymphoma.
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Affiliation(s)
- Kitsada Wudhikarn
- Division of Hematology, Mayo Clinic, Rochester, Minnesota; Division of Hematology and Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Bradley M Johnson
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Luis F Porrata
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Willam J Hogan
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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3
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Iovino L, Wu QV, Voutsinas J, Panaite L, Mullane E, Lynch RC, Ujjani C, Smith SD, Gopal AK, Till BG, Milano F, Chow V, Gauthier J, Turtle CJ, Maloney DG, Shadman M. Predictors of response to axicabtagene-ciloleucel CAR T cells in aggressive B cell lymphomas: A real-world study. J Cell Mol Med 2022; 26:5976-5983. [PMID: 36453136 PMCID: PMC9753434 DOI: 10.1111/jcmm.17550] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/06/2022] [Accepted: 07/29/2022] [Indexed: 12/03/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR T) therapy has shown promising efficacy in relapsed and refractory diffuse large B cell lymphoma (DLBCL). While most patients undergo CAR T infusion with active disease, the impact of some clinical variables, such as responsiveness to the pre-CAR T chemotherapy on the response to CAR T, is unknown. In this single-institution study, we studied the impact of several pre-CAR T variables on the post-CAR outcomes. Sixty patients underwent apheresis for axicabtagene-ciloleucel (axi-cel) and 42 of them (70.0%) had primary refractory disease. Bridging therapy between apheresis and lymphodepletion was given in 34 patients (56.7%). After axi-cel, the overall response rate was 63.3%. Responsiveness to the immediate pre-CAR T therapy did not show a significant association with response to axi-cel, progression-free (PFS) or overall (OS) survival. Multivariable analysis determined that bulky disease before lymphodepletion was independently associated with inferior outcomes, and patients that presented with high-burden disease unresponsive to immediate pre-CAR T therapy had a dismal outcome. This data supports proceeding with treatment in CAR T candidates regardless of their response to immediate pre-CAR T therapy. Interim therapeutic interventions should be considered in patients who have known risk factors for poor outcomes (bulky disease, high LDH).
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Affiliation(s)
- Lorenzo Iovino
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Qian Vicky Wu
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Jenna Voutsinas
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Lorena Panaite
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Erin Mullane
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Ryan C. Lynch
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Chaitra Ujjani
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Stephen D. Smith
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Ajay K. Gopal
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Brian G. Till
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Filippo Milano
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Victor Chow
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Jordan Gauthier
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Cameron J. Turtle
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - David G. Maloney
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Mazyar Shadman
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
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Abstract
PURPOSE OF REVIEW To summarize the recent evidence on the pathology, current standard of care and recent advances in the treatment of HIV-related lymphomas. RECENT FINDINGS Lymphomas remain a major cause of morbidity and mortality in people living with HIV, even in the era of combination antiretroviral therapy (cART). However, treatment outcomes for these malignancies have improved in recent decades, due to full-dose chemotherapy, effective cART and supportive care. Recent advances include the identification of novel driving signaling pathways as promising molecular targets to improve lymphoma outcomes. SUMMARY Patients with HIV-related lymphomas who receive effective cART should be treated like the general population.
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Loncastuximab tesirine in relapsed or refractory diffuse large B-cell lymphoma: a profile of its use in the USA. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00922-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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6
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Grigg A. Living Long and Well After an Autograft. J Clin Oncol 2022; 40:1971-1975. [PMID: 35512253 DOI: 10.1200/jco.22.00302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Andrew Grigg
- Department Clinical Haematology, Austin Hospital, Heidelberg, Melbourne, Australia
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7
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ABCs of ADCs in Management of Relapsed/refractory diffuse large B-cell lymphoma. Blood Rev 2022; 56:100967. [DOI: 10.1016/j.blre.2022.100967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 11/19/2022]
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8
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Wang C, Liu J, Liu Y. Progress in the Treatment of HIV-Associated Lymphoma When Combined With the Antiretroviral Therapies. Front Oncol 2022; 11:798008. [PMID: 35096597 PMCID: PMC8792758 DOI: 10.3389/fonc.2021.798008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/23/2021] [Indexed: 01/11/2023] Open
Abstract
With the wide use of combination antiretroviral therapy (cART), the life expectancy of HIV-infected individuals drastically improved. However, HIV infection and HIV-associated cancers were the most common causes of death in the HIV-infected populations. The HIV-associated cancers are divided into acquired immune deficiency syndrome (AIDS)-defining and non-AIDS-defining cancers based on the incidence among the HIV-infected patients. Among HIV-associated cancers, acquired immune deficiency syndrome-related lymphoma (ARL) is still the most common condition and the leading cause of HIV/AIDS-related deaths. Diffuse large B-cell lymphoma (DLBCL) and Burkitt’s lymphoma (BL) are the most common subtypes of the ARL. Although Hodgkin’s lymphoma (HL) is not considered as an AIDS-defining cancer, incidence of HL in HIV-infected individuals is higher than the general population. The review summarizes the new progress in the treatment of HIV-associated lymphoma.
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Affiliation(s)
- Chaoyu Wang
- Department of Hematology-Oncology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
| | - Jun Liu
- Department of Hematology-Oncology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
| | - Yao Liu
- Department of Hematology-Oncology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
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Alencar AJ, Hirayama AV, Clé DV, Salvino MA, Perini G, Arrais C, Baiocchi O, Palma LC, Colturato I, Vaz J, Chiattone R, de Lima M, Filho JS, Nabhan S, Rocha V, Guerino-Cunha RL, Chiattone CS. Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Consensus on genetically modified cells. III: anti-CD19 CAR-T cell therapy for patients with non-Hodgkin lymphoma. Hematol Transfus Cell Ther 2021; 43 Suppl 2:S22-S29. [PMID: 34794792 PMCID: PMC8606699 DOI: 10.1016/j.htct.2021.09.003] [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: 09/06/2021] [Accepted: 09/14/2021] [Indexed: 12/01/2022] Open
Abstract
The treatment and evolution of B-cell non-Hodgkin lymphoma (B-NHL) has undergone important changes in the last years with the emergence of targeted therapies, such as monoclonal antibodies, small molecules, antibody-drug conjugates, and bispecific antibodies. Nevertheless, a significant portion of patients remains refractory or relapsed (R/R) to the new therapeutic modalities, representing thus an unmet medical need. The use of CAR-T cells for the treatment of B-NHL patients has shown to be a promising therapy with impressive results in patients with R/R disease. The expectations are as high as the imminent approval of CAR-T cell therapy in Brazil, which it is expected to impact the prognosis of R/R B-NHL. The aim of this manuscript is to offer a consensus of specialists in the field of onco-hematology and cellular therapy, working in Brazil and United States, in order to discuss and offer recommendations in the present setting of the use of CAR-T cells for patients with B-NHL.
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Affiliation(s)
- Alvaro J Alencar
- Sylvester Comprehensive Cancer Center, Universidade de Miami Miller School of Medicine, Miami, FL, USA
| | | | - Diego V Clé
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | | | - Celso Arrais
- Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil; Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Otávio Baiocchi
- Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - Leonardo Carvalho Palma
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | | | - Jorge Vaz
- Centro de Câncer de Brasilia (CETTRO), Brasilia, DF, Brazil
| | | | | | | | - Samir Nabhan
- Hospital de Clínicas - Universidade Federal do Paraná, (HC UFPR), Curitiba, PR, Brazil
| | - Vanderson Rocha
- Hospital das Clínicas, Universidade de São Paulo, (HC USP), São Paulo, SP, Brazil; Hospital Vila Nova Star, São Paulo, SP, Brazil
| | - Renato L Guerino-Cunha
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Carlos S Chiattone
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil.
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Metzner B, Welzel J, Müller TH, Casper J, Kimmich C, Petershofen EK, Renzelmann A, Rosien B, Thole R, Voss A, Willborn K, Köhne CH. Long-term remissions in patients with early relapse of diffuse large B-cell lymphoma following high-dose chemotherapy, autologous stem cell transplantation, and radiotherapy of residual disease. Strahlenther Onkol 2021; 198:39-46. [PMID: 34735577 DOI: 10.1007/s00066-021-01868-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/03/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The prognosis of an early relapse of diffuse large B-cell lymphoma (DLBCL) appears to be poor following autologous stem cell transplantation (ASCT). The aim of this study is to contribute data to the open question on whether additional radiotherapy can improve the outcome. PATIENTS AND METHODS Forty-eight patients with an early relapse (median 4 months after the end of initial immunochemotherapy, range 1-11) of DLBCL have been treated in our institution with high-dose therapy (usually the BEAM protocol) and ASCT since 2008 (median age 61 years, range 28-73). Twenty-three patients received ASCT in a second treatment line, 25 in a third line (19 refractory to second-line salvage therapy, 5 after second relapse). Fifteen of these 48 patients received radiotherapy (36-50 Gy, median 40) of residual masses after ASCT. RESULTS Three-year overall survival (OS) and progression-free survival (PFS) after second-line ASCT were 61 and 57%, after third-line ASCT 47 and 44%, respectively, without significant differences. A prognostic factor was the International Prognostic Index (IPI) at the start of salvage therapy. Three-year OS and PFS in low-risk patients were 69 and 69%, in low-intermediate-risk 63 and 53%, and in high-intermediate-risk 23 and 23%, respectively (p = 0.033). Twenty-three patients achieved a sustained complete remission (13-146 months, median 62). CONCLUSION Sustained long-term remissions can be achieved in patients with early relapse of DLBCL following ASCT in a second or third treatment line, particularly in patients with low- and low-intermediate-risk IPI, following radiotherapy of residual disease after ASCT. Further investigations are required to clarify which patients need an alternative therapy (potentially CAR T‑cells or allogeneic transplantation).
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Affiliation(s)
- Bernd Metzner
- Department of Oncology and Hematology, Klinikum Oldenburg, University Clinic, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany.
| | - Jutta Welzel
- University Clinic for Radiotherapy and Radiooncology, Pius-Hospital Oldenburg, Oldenburg, Germany
| | - Thomas H Müller
- Red Cross Blood Transfusion Service NSTOB, Oldenburg, Germany
| | - Jochen Casper
- Department of Oncology and Hematology, Klinikum Oldenburg, University Clinic, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| | - Christoph Kimmich
- Department of Oncology and Hematology, Klinikum Oldenburg, University Clinic, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| | | | - Andrea Renzelmann
- Department of Oncology and Hematology, Klinikum Oldenburg, University Clinic, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| | - Bernd Rosien
- Department of Oncology and Hematology, Klinikum Oldenburg, University Clinic, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| | - Ruth Thole
- Department of Oncology and Hematology, Klinikum Oldenburg, University Clinic, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| | - Andreas Voss
- Department of Oncology and Hematology, Klinikum Oldenburg, University Clinic, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| | - Kay Willborn
- University Clinic for Radiotherapy and Radiooncology, Pius-Hospital Oldenburg, Oldenburg, Germany
| | - Claus Henning Köhne
- Department of Oncology and Hematology, Klinikum Oldenburg, University Clinic, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
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11
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Affiliation(s)
- Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital Edgbaston, Birmingham, United Kingdom.,CRCTU Clinical Trial Unit, University of Birmingham, Birmingham, United Kingdom
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