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Shadman M, Manzoor BS, Sail K, Tuncer HH, Allan JN, Ujjani C, Emechebe N, Kamalakar R, Coombs CC, Leslie L, Barr PM, Brown JR, Eyre TA, Rampotas A, Schuh A, Lamanna N, Skarbnik A, Roeker LE, Bannerji R, Eichhorst B, Fleury I, Davids MS, Alhasani H, Jiang D, Hill BT, Schuster SJ, Brander DM, Pivneva I, Burne R, Guerin A, Mato AR. Treatment Discontinuation Patterns for Patients With Chronic Lymphocytic Leukemia in Real-World Settings: Results From a Multi-Center International Study. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023:S2152-2650(23)00107-6. [PMID: 37076367 DOI: 10.1016/j.clml.2023.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION This study assessed treatment discontinuation patterns and reasons among chronic lymphocytic leukemia (CLL) patients initiating first-line (1L) and second-line (2L) treatments in real-world settings. MATERIALS AND METHODS Using deidentified electronic medical records from the CLL Collaborative Study of Real-World Evidence, premature treatment discontinuation was assessed among FCR, BR, BTKi-based, and BCL-2-based regimen cohorts. RESULTS Of 1364 1L patients (initiated in 1997-2021), 190/13.9% received FCR (23.7% discontinued prematurely); 255/18.7% received BR (34.5% discontinued prematurely); 473/34.7% received BTKi-based regimens, of whom 28.1% discontinued prematurely; and 43/3.2% received venetoclax-based regimens, of whom 16.3% discontinued prematurely (venetoclax monotherapy: 7/0.5%, of whom 42.9% discontinued; VG/VR: 36/2.6%, of whom 11.1% discontinued). The most common reasons for treatment discontinuation were adverse events (FCR: 25/13.2%; BR: 36/14.1%; BTKi-based regimens: 75/15.9%) and disease progression (venetoclax-based: 3/7.0%). Of 626 2L patients, 20/3.2% received FCR (50.0% discontinued); 62/9.9% received BR (35.5% discontinued); 303/48.4% received BTKi-based regimens, of whom 38.0% discontinued; and 73/11.7% received venetoclax-based regimens, of whom 30.1% discontinued (venetoclax monotherapy: 27/4.3%, of whom 29.6% discontinued; VG/VR: 43/6.9%, of whom 27.9% discontinued). The most common reasons for treatment discontinuation were adverse events (FCR: 6/30.0%; BR: 11/17.7%; BTKi-based regimens: 60/19.8%; venetoclax-based: 6/8.2%). CONCLUSION The findings of this study highlight the continued need for tolerable therapies in CLL, with finite therapy offering a better tolerated option for patients who are newly diagnosed or relapsed/refractory to prior treatments.
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Affiliation(s)
- Mazyar Shadman
- Fred Hutch Cancer Center and University of Washington, Seattle, WA
| | | | | | - Hande H Tuncer
- The Cancer Center at Lowell General Hospital, Lowell, MA
| | | | - Chaitra Ujjani
- Fred Hutch Cancer Center and University of Washington, Seattle, WA
| | | | | | - Catherine C Coombs
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lori Leslie
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ
| | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | | | - Toby A Eyre
- Churchill Hospital, Oxford University, Oxford, UK
| | | | - Anna Schuh
- Churchill Hospital, Oxford University, Oxford, UK
| | - Nicole Lamanna
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
| | | | - Lindsey E Roeker
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rajat Bannerji
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Barbara Eichhorst
- Department of Internal Medicine, Center of Integrated Oncology Köln Bonn, University of Cologne, Cologne, Germany
| | | | | | | | | | | | - Stephen J Schuster
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | - Anthony R Mato
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Furman RR, Byrd JC, Owen RG, O'Brien SM, Brown JR, Hillmen P, Stephens DM, Chernyukhin N, Lezhava T, Hamdy AM, Izumi R, Patel P, Baek M, Christian B, Dyer MJS, Streetly MJ, Sun C, Rule S, Wang M, Ghia P, Jurczak W, Pagel JM, Sharman JP. Pooled analysis of safety data from clinical trials evaluating acalabrutinib monotherapy in mature B-cell malignancies. Leukemia 2021; 35:3201-3211. [PMID: 33907299 DOI: 10.1038/s41375-021-01252-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 03/19/2021] [Accepted: 04/06/2021] [Indexed: 01/04/2023]
Abstract
Bruton tyrosine kinase (BTK) inhibition is an effective therapy for many B-cell malignancies. Acalabrutinib is a next-generation, potent, highly selective, covalent BTK inhibitor. To characterize acalabrutinib tolerability, we pooled safety data from 1040 patients with mature B-cell malignancies treated with acalabrutinib monotherapy in nine clinical studies (treatment-naïve: n = 366 [35%], relapsed/refractory: n = 674 [65%]; median [range] age: 67 [32-90] years; median [range] prior treatments: 1 [0-13]; median [range] duration of exposure: 24.6 [0.0-58.5] months). The most common adverse events (AEs) were headache (38%), diarrhea (37%), upper respiratory tract infection (22%), contusion (22%), nausea (22%), fatigue (21%), and cough (21%). Serious AEs (SAEs) occurred in 39% of patients; pneumonia (6%) was the only SAE that occurred in ≥2%. Deaths due to AEs occurred in 52 patients (5%); pneumonia (n = 8) was the only fatal AE to occur in ≥3 patients. AEs led to treatment discontinuation in 9%. Rates for the AEs of interest (all grades) included infections (67%), hemorrhages (46%), neutropenia (16%), anemia (14%), second primary malignancies (12%), thrombocytopenia (9%), hypertension (8%), and atrial fibrillation (4%). This pooled analysis confirmed acalabrutinib's tolerability and identified no newly emerging late toxicities, supporting acalabrutinib as a long-term treatment for patients with mature B-cell malignancies.
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Affiliation(s)
- Richard R Furman
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA.
| | - John C Byrd
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | - Susan M O'Brien
- Chao Family Comprehensive Cancer Center, University of California-Irvine, Irvine, CA, USA
| | | | | | | | | | | | | | | | | | | | - Beth Christian
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Martin J S Dyer
- The Ernest and Helen Scott Haematological Research Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Clare Sun
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Simon Rule
- Plymouth University Medical School, Plymouth, UK
| | - Michael Wang
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milano, Italy
| | - Wojciech Jurczak
- Maria Sklodowska-Curie National Research Institute of Oncology, Krakow, Poland
| | | | - Jeff P Sharman
- Willamette Valley Cancer Institute/US Oncology, Eugene, OR, USA
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Al‐Katib AM, Gaith H, Sano D, Al‐Katib S, Bonnett M, Kafri Z. Emergence of overt myeloma in a patient with chronic lymphocytic leukemia on ibrutinib therapy. Clin Case Rep 2020; 8:1797-1801. [PMID: 32983498 PMCID: PMC7495781 DOI: 10.1002/ccr3.3019] [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: 02/19/2020] [Revised: 04/20/2020] [Accepted: 05/12/2020] [Indexed: 11/09/2022] Open
Abstract
Ibrutinib is approved for chronic lymphocytic leukemia (CLL). However, its role in the treatment of multiple myeloma (MM) is not clear and is under investigation. We report a case of CLL that developed MM while on therapy with ibrutinib indicating that this drug may not be active against MM.
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Affiliation(s)
- Ayad M. Al‐Katib
- Lymphoma Research LaboratoryDepartment of Internal MedicineWayne State University School of Medicine (WSU SOM)DetroitMIUSA
| | - Hussein Gaith
- Lymphoma Research LaboratoryDepartment of Internal MedicineWayne State University School of Medicine (WSU SOM)DetroitMIUSA
| | - Dahlia Sano
- Department of OncologyKarmanos Cancer InstituteWSU SOMDetroitMIUSA
| | - Sayf Al‐Katib
- Department of Diagnostic Radiology and Molecular ImagingBeaumont HealthOakland University William Beaumont School of MedicineRoyal OakMIUSA
| | - Michelle Bonnett
- Department of PathologyAscension St. John Hospital and Medical CenterDetroitMIUSA
| | - Zyad Kafri
- Van Elslander Cancer CenterGrosse Pointe WoodsMIUSA
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Barcellini W, Giannotta J, Fattizzo B. Autoimmune hemolytic anemia in adults: primary risk factors and diagnostic procedures. Expert Rev Hematol 2020; 13:585-597. [PMID: 32274943 DOI: 10.1080/17474086.2020.1754791] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) is due to autoantibodies against erythrocytes that may arise either because of primary tolerance breakage or along with several associated conditions, including genetic predispositions, congenital syndromes, environmental triggers, autoimmune diseases, immunodeficiencies, and neoplasms. AREAS COVERED This review evaluated the risk of AIHA development in associated conditions and summarized disease-intrinsic risk factors for relapse and outcome. Diagnostic procedures were analyzed to properly identify primary and secondary forms. A Medline including clinical trials, meta-analyses, guidelines, consensus, and case reports, published in the last 30 years were performed. EXPERT OPINION The several associated conditions listed above constitute a risk for AIHA development and should be considered since disease course and therapy may be different. Particularly, AIHA developing after transplant or novel checkpoint inhibitors is an emerging complex entity whose proper therapy is still an unmet need. Concerning intrinsic risk factors, the severity of anemia at onset correlated with the recurrence of relapses, refractoriness, and fatal outcome. This finding reflects the presence of several mechanisms involved in AIHA, i.e. highly pathogenic antibodies, complement activation, and failure of marrow compensation. With the advent of novel target therapies (complement and various tyrosine kinase inhibitors), a risk-adapted therapy for AIHA is becoming fundamental.
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Affiliation(s)
- Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Juri Giannotta
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy.,Università degli Studi di Milano , Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy.,Università degli Studi di Milano , Milan, Italy
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Skånland SS, Cremaschi A, Bendiksen H, Hermansen JU, Thimiri Govinda Raj DB, Munthe LA, Tjønnfjord GE, Taskén K. An in vitro assay for biomarker discovery and dose prediction applied to ibrutinib plus venetoclax treatment of CLL. Leukemia 2019; 34:478-487. [DOI: 10.1038/s41375-019-0569-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/08/2019] [Accepted: 07/17/2019] [Indexed: 01/10/2023]
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Giannoni P, Fais F, Cutrona G, Totero DD. Hepatocyte Growth Factor: A Microenvironmental Resource for Leukemic Cell Growth. Int J Mol Sci 2019; 20:ijms20020292. [PMID: 30642077 PMCID: PMC6359660 DOI: 10.3390/ijms20020292] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 02/08/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is characterized by the progressive expansion of B lymphocytes CD5+/CD23+ in peripheral blood, lymph-nodes, and bone marrow. The pivotal role played by the microenvironment in disease pathogenesis has become increasingly clear. We demonstrated that bone marrow stromal cells and trabecular bone cells sustain survival of leukemic B cells through the production of hepatocyte growth factor (HGF). Indeed the trans-membrane kinase receptor for HGF, c-MET, is expressed on CLL cells and STAT3 TYR705 or AKT phosphorylation is induced after HGF/c-MET interaction. We have further observed that c-MET is also highly expressed in a peculiar type of cells of the CLL-microenvironment showing nurturing features for the leukemic clone (nurse-like cells: NLCs). Since HGF treatment drives monocytes toward the M2 phenotype and NLCs exhibit features of tumor associated macrophages of type 2 we suggested that HGF, released either by cells of the microenvironment or leukemic cells, exerts a double effect: (i) enhances CLL cells survival and (ii) drives differentiation of monocytes-macrophages to an oriented immune suppressive phenotype. We here discuss how paracrine, but also autocrine production of HGF by malignant cells, may favor leukemic clone expansion and resistance to conventional drug treatments in CLL, as well as in other hematological malignancies. Novel therapeutic approaches aimed to block HGF/c-MET interactions are further proposed.
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Affiliation(s)
- Paolo Giannoni
- Stem Cell Laboratory, Department of Experimental Medicine, University of Genoa, V. Pastore 3, 16132 Genova, Italy.
| | - Franco Fais
- Molecular Pathology Unit, IRCCS Polyclinic Hospital San Martino, L.go R. Benzi n.10, 16132 Genova, Italy.
| | - Giovanna Cutrona
- Molecular Pathology Unit, IRCCS Polyclinic Hospital San Martino, L.go R. Benzi n.10, 16132 Genova, Italy.
| | - Daniela de Totero
- Molecular Pathology Unit, IRCCS Polyclinic Hospital San Martino, L.go R. Benzi n.10, 16132 Genova, Italy.
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Amigo-Jiménez I, Bailón E, Aguilera-Montilla N, García-Marco JA, García-Pardo A. Gene expression profile induced by arsenic trioxide in chronic lymphocytic leukemia cells reveals a central role for heme oxygenase-1 in apoptosis and regulation of matrix metalloproteinase-9. Oncotarget 2018; 7:83359-83377. [PMID: 27829220 PMCID: PMC5347775 DOI: 10.18632/oncotarget.13091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 10/21/2016] [Indexed: 12/20/2022] Open
Abstract
CLL remains an incurable disease in spite of the many new compounds being tested. Arsenic trioxide (ATO) induces apoptosis in all CLL cell types and could constitute an efficient therapy. To further explore this, we have studied the gene expression profile induced by ATO in CLL cells. ATO modulated many genes, largely involved in oxidative stress, being HMOX1 the most upregulated gene, also induced at the protein level. ATO also increased MMP-9, as we previously observed, both at the mRNA and protein level. Using specific inhibitors, qPCR analyses, and gene silencing approaches we demonstrate that upregulation of MMP-9 by ATO involved activation of the p38 MAPK/AP-1 signaling pathway. Moreover, gene silencing HMOX1 or inhibiting HMOX1 activity enhanced p38 MAPK phosphorylation and c-jun expression/activation, resulting in transcriptional upregulation of MMP-9. Overexpression of HMOX1 or enhancement of its activity, had the opposite effect. Cell viability analyses upon modulation of HMOX1 expression or activity demonstrated that HMOX1 had a pro-apoptotic role and enhanced the cytotoxic effect of ATO in CLL cells. We have therefore identified a new mechanism in which HMOX1 plays a central role in the response of CLL cells to ATO and in the regulation of the anti-apoptotic protein MMP-9. Thus, HMOX1 arises as a new therapeutic target in CLL and the combination of HMOX1 modulators with ATO may constitute an efficient therapeutic strategy in CLL.
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Affiliation(s)
- Irene Amigo-Jiménez
- Cellular and Molecular Medicine Department, Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - Elvira Bailón
- Cellular and Molecular Medicine Department, Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - Noemí Aguilera-Montilla
- Cellular and Molecular Medicine Department, Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - José A García-Marco
- Molecular Cytogenetics Unit, Hematology Department, Instituto de Investigación Sanitaria Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Angeles García-Pardo
- Cellular and Molecular Medicine Department, Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
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Low catalase expression confers redox hypersensitivity and identifies an indolent clinical behavior in CLL. Blood 2018; 131:1942-1954. [PMID: 29467184 DOI: 10.1182/blood-2017-08-800466] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 02/17/2018] [Indexed: 11/20/2022] Open
Abstract
B-cell receptor (BCR) signaling is a key determinant of variable clinical behavior and a target for therapeutic interventions in chronic lymphocytic leukemia (CLL). Endogenously produced H2O2 is thought to fine-tune the BCR signaling by reversibly inhibiting phosphatases. However, little is known about how CLL cells sense and respond to such redox cues and what effect they have on CLL. We characterized the response of BCR signaling proteins to exogenous H2O2 in cells from patients with CLL, using phosphospecific flow cytometry. Exogenous H2O2 in the absence of BCR engagement induced a signaling response of BCR proteins that was higher in CLL with favorable prognostic parameters and an indolent clinical course. We identified low catalase expression as a possible mechanism accounting for redox signaling hypersensitivity. Decreased catalase could cause an escalated accumulation of exogenous H2O2 in leukemic cells with a consequent greater inhibition of phosphatases and an increase of redox signaling sensitivity. Moreover, lower levels of catalase were significantly associated with a slower progression of the disease. In leukemic cells characterized by redox hypersensitivity, we also documented an elevated accumulation of ROS and an increased mitochondrial amount. Taken together, our data identified redox sensitivity and metabolic profiles that are linked to differential clinical behavior in CLL. This study advances our understanding of the redox and signaling heterogeneity of CLL and provides the rationale for the development of therapies targeting redox pathways in CLL.
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Microenvironment-induced CD44v6 promotes early disease progression in chronic lymphocytic leukemia. Blood 2018; 131:1337-1349. [PMID: 29352038 DOI: 10.1182/blood-2017-08-802462] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 01/11/2018] [Indexed: 01/01/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) outgrowth depends on signals from the microenvironment. We have previously found that in vitro reconstitution of this microenvironment induces specific variant isoforms of the adhesion molecule CD44, which confer human CLL with high affinity to hyaluronan (HA). Here, we determined the in vivo contribution of standard CD44 and its variants to leukemic B-cell homing and proliferation in Tcl1 transgenic mice with a B-cell-specific CD44 deficiency. In these mice, leukemia onset was delayed and leukemic infiltration of spleen, liver, and lungs, but not of bone marrow, was decreased. Competitive transplantation revealed that CLL homing to spleen and bone marrow required functional CD44. Notably, enrichment of CD44v6 variants particularly in spleen enhanced CLL engraftment and proliferation, along with increased HA binding. We recapitulated CD44v6 induction in the human disease and revealed the involvement of MAPK and NF-κB signaling upon CD40 ligand and B-cell receptor stimulation by in vitro inhibition experiments and chromatin immunoprecipitation assays. The investigation of downstream signaling after CD44v6-HA engagement uncovered the activation of extracellular signal-regulated kinase and p65. Consequently, anti-CD44v6 treatment reduced leukemic cell proliferation in vitro in human and mouse, confirming the general nature of the findings. In summary, we propose a CD44-NF-κB-CD44v6 circuit in CLL, allowing tumor cells to gain HA binding capacity and supporting their proliferation.
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Agarwal N, Ahmed R, Bhurani D. Blood cancers: Flowing the right way! ASIAN JOURNAL OF ONCOLOGY 2016. [DOI: 10.4103/2454-6798.180587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Narendra Agarwal
- Department of Medical Oncology, Division of Hematolo-oncology Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Rayaz Ahmed
- Department of Medical Oncology, Division of Hematolo-oncology Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Dinesh Bhurani
- Department of Medical Oncology, Division of Hematolo-oncology Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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