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Waldenström Macroglobulinemia: Mechanisms of Disease Progression and Current Therapies. Int J Mol Sci 2022; 23:ijms231911145. [PMID: 36232447 PMCID: PMC9569492 DOI: 10.3390/ijms231911145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/12/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Waldenström macroglobulinemia is an indolent, B-cell lymphoma without a known cure. The bone marrow microenvironment and cytokines both play key roles in Waldenström macroglobulinemia (WM) tumor progression. Only one FDA-approved drug exists for the treatment of WM, Ibrutinib, but treatment plans involve a variety of drugs and inhibitors. This review explores avenues of tumor progression and targeted drug therapy that have been investigated in WM and related B-cell lymphomas.
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Klemencic S, Perkins J. Diagnosis and Management of Oncologic Emergencies. West J Emerg Med 2019; 20:316-322. [PMID: 30881552 PMCID: PMC6404710 DOI: 10.5811/westjem.2018.12.37335] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
Oncologic emergencies may be seen in any emergency department and will become more frequent as our population ages and more patients receive chemotherapy. Life-saving interventions are available for certain oncologic emergencies if the diagnosis is made in a timely fashion. In this article we will cover neutropenic fever, tumor lysis syndrome, hypercalcemia of malignancy, and hyperviscosity syndrome. After reading this article the reader should be much more confident in the diagnosis, evaluation, and management of these oncologic emergencies.
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Affiliation(s)
- Sarah Klemencic
- Virginia Tech Carilion School of Medicine, Department of Emergency Medicine, Roanoke, Virginia
| | - Jack Perkins
- Virginia Tech Carilion School of Medicine, Department of Emergency Medicine, Roanoke, Virginia
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Cao X, Medeiros LJ, Xia Y, Wang X, Thomas SK, Loghavi S, Li X, Shah JJ, Gustafson SA, Weber DM, Miranda RN, Xu-Monette ZY, Orlowski RZ, Young KH. Clinicopathologic features and outcomes of lymphoplasmacytic lymphoma patients with monoclonal IgG or IgA paraprotein expression. Leuk Lymphoma 2015; 57:1104-13. [DOI: 10.3109/10428194.2015.1096357] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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The many faces of small B cell lymphomas with plasmacytic differentiation and the contribution of MYD88 testing. Virchows Arch 2015; 468:259-75. [PMID: 26454445 DOI: 10.1007/s00428-015-1858-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/23/2015] [Indexed: 12/11/2022]
Abstract
Plasmacytic differentiation may occur in almost all small B cell lymphomas (SBLs), although it varies from being uniformly present (as in lymphoplasmacytic lymphoma (LPL)) to very uncommon (as in mantle cell lymphomas (MCLs)). The discovery of MYD88 L265P mutations in the vast majority of LPLs has had a major impact on the study of these lymphomas. Review of the cases contributed to the 2014 European Association for Haematopathology/Society for Hematopathology slide workshop illustrated how mutational testing has helped refine the diagnostic criteria for LPL, emphasizing the importance of identifying a clonal monotonous lymphoplasmacytic population and highlighting how LPL can still be diagnosed with extensive nodal architectural effacement, very subtle plasmacytic differentiation, follicular colonization, or uncommon phenotypes such as CD5 or CD10 expression. MYD88 L265P mutations were found in 11/11 LPL cases versus only 2 of 28 other SBLs included in its differential diagnosis. Mutational testing also helped to exclude other cases that would have been considered LPL in the past. The workshop also highlighted how plasmacytic differentiation can occur in chronic lymphocytic leukemia/small lymphocytic lymphoma, follicular lymphoma, SOX11 negative MCL, and particularly in marginal zone lymphomas, all of which can cause diagnostic confusion with LPL. The cases also highlighted the difficulty in distinguishing lymphomas with marked plasmacytic differentiation from plasma cell neoplasms. Some SBLs with plasmacytic differentiation can be associated with amyloid, other immunoglobulin deposition, or crystal-storing histiocytosis, which may obscure the underlying neoplasm. Finally, although generally indolent, LPL may transform, with the workshop cases suggesting a role for TP53 abnormalities.
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Lipsky AH, Farooqui MZH, Tian X, Martyr S, Cullinane AM, Nghiem K, Sun C, Valdez J, Niemann CU, Herman SEM, Saba N, Soto S, Marti G, Uzel G, Holland SM, Lozier JN, Wiestner A. Incidence and risk factors of bleeding-related adverse events in patients with chronic lymphocytic leukemia treated with ibrutinib. Haematologica 2015; 100:1571-8. [PMID: 26430171 DOI: 10.3324/haematol.2015.126672] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 09/24/2015] [Indexed: 01/11/2023] Open
Abstract
Ibrutinib is associated with bleeding-related adverse events of grade ≤ 2 in severity, and infrequently with grade ≥ 3 events. To investigate the mechanisms of bleeding and identify patients at risk, we prospectively assessed platelet function and coagulation factors in our investigator-initiated trial of single-agent ibrutinib for chronic lymphocytic leukemia. At a median follow-up of 24 months we recorded grade ≤ 2 bleeding-related adverse events in 55% of 85 patients. No grade ≥ 3 events occurred. Median time to event was 49 days. The cumulative incidence of an event plateaued by 6 months, suggesting that the risk of bleeding decreases with continued therapy. At baseline, von Willebrand factor and factor VIII levels were often high and normalized on treatment. Platelet function measured via the platelet function analyzer (PFA-100™) was impaired in 22 patients at baseline and in an additional 19 patients on ibrutinib (often transiently). Collagen and adenosine diphosphate induced platelet aggregation was tested using whole blood aggregometry. Compared to normal controls, response to both agonists was decreased in all patients with chronic lymphocytic leukemia, whether on ibrutinib or not. Compared to untreated chronic lymphocytic leukemia patients, response to collagen showed a mild further decrement on ibrutinib, while response to adenosine diphosphate improved. All parameters associated with a significantly increased risk of bleeding-related events were present at baseline, including prolonged epinephrine closure time (HR 2.74, P=0.012), lower levels of von Willebrand factor activity (HR 2.73, P=0.009) and factor VIII (HR 3.73, P=0.0004). In conclusion, both disease and treatment-related factors influence the risk of bleeding. Patients at greater risk for bleeding of grade ≤ 2 can be identified by clinical laboratory tests and counseled to avoid aspirin, non-steroidal anti-inflammatory drugs and fish oils. ClinicalTrials.gov identifier NCT01500733.
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Affiliation(s)
- Andrew H Lipsky
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA Department of Internal Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Mohammed Z H Farooqui
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Xin Tian
- Office of Biostatistics Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Sabrina Martyr
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ann M Cullinane
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, MD, USA
| | - Khanh Nghiem
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, MD, USA
| | - Clare Sun
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Janet Valdez
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Carsten U Niemann
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Sarah E M Herman
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nakhle Saba
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Susan Soto
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Gerald Marti
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Gulbu Uzel
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Steve M Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jay N Lozier
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, MD, USA
| | - Adrian Wiestner
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Phase I/II trial of everolimus in combination with bortezomib and rituximab (RVR) in relapsed/refractory Waldenstrom macroglobulinemia. Leukemia 2015; 29:2338-46. [DOI: 10.1038/leu.2015.164] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/07/2015] [Accepted: 05/15/2015] [Indexed: 12/17/2022]
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Chakraborty R, Kapoor P, Ansell SM, Gertz MA. Ibrutinib for the treatment of Waldenström macroglobulinemia. Expert Rev Hematol 2015; 8:569-79. [PMID: 26138997 DOI: 10.1586/17474086.2015.1061427] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Waldenström macroglobulinemia (WM) is a B-cell non-Hodgkin lymphoma (NHL) characterized by IgM monoclonal gammopathy and bone marrow infiltration by lymphoplasmacytic cells. Until recently, there was no drug specifically approved for WM by the US FDA, leading to wide variations in therapeutic strategies across the globe. Ibrutinib, an oral Bruton tyrosine kinase (BTK) inhibitor, is the first drug approved specifically for WM by the FDA after a clinical trial showed impressive response in previously treated WM. Ibrutinib is a non-stem cell toxic and non-neurotoxic option and suitable for long-term oral maintenance therapy, with the potential of improving survival in WM. With identification of novel genetic mutations impacting response to ibrutinib, it would be possible to individualize therapy based on MYD88 and CXCR4 genotypes. However, long-term safety and efficacy data are required, and cost-effectiveness needs to be addressed before ibrutinib can gain widespread acceptance for front-line therapy of WM.
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Leblebjian H, Noonan K, Paba-Prada C, Treon SP, Castillo JJ, Ghobrial IM. Cyclophosphamide, bortezomib, and dexamethasone combination in waldenstrom macroglobulinemia. Am J Hematol 2015; 90:E122-3. [PMID: 25703132 DOI: 10.1002/ajh.23985] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/17/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Houry Leblebjian
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Kimberly Noonan
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Claudia Paba-Prada
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Steven P. Treon
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Jorge J. Castillo
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Irene M. Ghobrial
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
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Chakraborty R, Ansell SA, Kapoor P, Gertz MA. Phase II clinical trials for Waldenstrom’s macroglobulinemia. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1025749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kuiatse I, Baladandayuthapani V, Lin HY, Thomas SK, Bjorklund CC, Weber DM, Wang M, Shah JJ, Zhang XD, Jones RJ, Ansell SM, Yang G, Treon SP, Orlowski RZ. Targeting the Spleen Tyrosine Kinase with Fostamatinib as a Strategy against Waldenström Macroglobulinemia. Clin Cancer Res 2015; 21:2538-45. [PMID: 25748087 DOI: 10.1158/1078-0432.ccr-14-1462] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 02/06/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Waldenström macroglobulinemia (WMG) is a lymphoproliferative disorder characterized by good initial responses to standard therapeutics, but only a minority of patients achieve complete remissions, and most inevitably relapse, indicating a need for novel agents. B-cell receptor signaling has been linked to clonal evolution in WMG, and Spleen tyrosine kinase (Syk) is overexpressed in primary cells, suggesting that it could be a novel and rational target. EXPERIMENTAL DESIGN We studied the impact of the Syk inhibitor fostamatinib on BCWM.1 and MWCL-1 WMG-derived cell lines both in vitro and in vivo, as well as on primary patient cells. RESULTS In WMG-derived cell lines, fostamatinib induced a time- and dose-dependent reduction in viability, associated with activation of apoptosis. At the molecular level, fostamatinib reduced activation of Syk and Bruton's tyrosine kinase, and also downstream signaling through MAPK kinase (MEK), p44/42 MAPK, and protein kinase B/Akt. As a single agent, fostamatinib induced tumor growth delay in an in vivo model of WMG, and reduced viability of primary WMG cells, along with inhibition of p44/42 MAPK signaling. Finally, fostamatinib in combination with other agents, including dexamethasone, bortezomib, and rituximab, showed enhanced activity. CONCLUSIONS Taken together, these data support the translation of approaches targeting Syk with fostamatinib to the clinic for patients with relapsed and possibly even newly diagnosed WMG.
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Affiliation(s)
- Isere Kuiatse
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Heather Y Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sheeba K Thomas
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chad C Bjorklund
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Donna M Weber
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Wang
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jatin J Shah
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xing-Ding Zhang
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard J Jones
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Guang Yang
- Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Steven P Treon
- Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas. Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Wiestner A. BCR pathway inhibition as therapy for chronic lymphocytic leukemia and lymphoplasmacytic lymphoma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:125-134. [PMID: 25696845 DOI: 10.1182/asheducation-2014.1.125] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Chronic lymphocytic leukemia (CLL) and lymphoplasmacytic lymphoma (LPL) are malignancies of mature B cells. In LPL, mutations of the adaptor protein MYD88 (L265P) in the Toll-like receptor pathway have been recognized recently as being a hallmark of the disease and indicate a dependence of the tumor on this pathway. In CLL, functional studies have implicated BCR activation in the tissue microenvironment as a pivotal pathway in the pathogenesis. Bruton's tyrosine kinase (BTK) and the PI3Kδ isoform are essential for BCR signaling and also seem to be required for signal transduction in LPL cells, even if the role of BCR signaling in this disease remains less well defined. Ibrutinib, a covalent inhibitor of BTK approved by the Food and Drug Administration as a second-line treatment for CLL, and idelalisib, a selective inhibitor of PI3Kδ, achieve excellent clinical responses in both diseases irrespective of classic markers indicating high-risk disease. Several additional inhibitors targeting BTK and PI3Kδ, as well as the spleen tyrosine kinase, have entered clinical trials. This review discusses the biologic basis for kinase inhibitors as targeted therapy for CLL and LPL and summarizes the clinical experience with these agents.
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Affiliation(s)
- Adrian Wiestner
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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Sahin I, Azab F, Mishima Y, Moschetta M, Tsang B, Glavey SV, Manier S, Zhang Y, Sacco A, Roccaro AM, Azab AK, Ghobrial IM. Targeting survival and cell trafficking in multiple myeloma and Waldenstrom macroglobulinemia using pan-class I PI3K inhibitor, buparlisib. Am J Hematol 2014; 89:1030-6. [PMID: 25060991 DOI: 10.1002/ajh.23814] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 07/18/2014] [Accepted: 07/21/2014] [Indexed: 01/13/2023]
Abstract
The phosphatidylinositol-3 kinase (PI3K) pathway is activated in multiple myeloma (MM) and Waldenstrom Macroglobulenima (WM), and plays a crucial role in tumor progression and drug resistance. In this study, we characterized the role of pan-class I PI3K inhibition on cell trafficking and survival of MM and WM cells. We tested the effect of pan-class I PI3K inhibition by siRNA silencing or pharmacologic inhibition with buparlisib on MM cell survival, apoptosis and cell cycle in vitro and tumor growth and mobilization of MM cells in vivo. We then evaluated buparlisib-dependent mechanisms of induced MM cell mobilization. Moreover, the effect of buparlisib on cell survival, apoptosis, and adhesion of WM cells to bone marrow stromal cells (BMSCs) has been evaluated. We showed that buparlisib induced toxicity in MM cells, supported by induction of apoptosis and cell cycle arrest. Buparlisib was also found to reduce tumor progression in vivo. Importantly, buparlisib enhanced MM cell mobilization in vivo which was driven by decreased adhesion of MM cells to BMSCs and increased chemotaxis via up-regulation of CXCR4 expression. Similar to its effects on MM cells, buparlisib also induced cell survival and apoptosis, and decreased adhesion in WM cells. These data highlight the critical contribution of class I PI3K signaling to the regulation of survival and cell dissemination in B-cell malignancies.
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Affiliation(s)
- Ilyas Sahin
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Feda Azab
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
- Department of Radiation Oncology, Cancer Biology Division, School of Medicine; Washington University in St. Louis; St. Louis Missouri
| | - Yuji Mishima
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Michele Moschetta
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Brian Tsang
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Siobhan V. Glavey
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Salomon Manier
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Yu Zhang
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Antonio Sacco
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Aldo M. Roccaro
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Abdel Kareem Azab
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
- Department of Radiation Oncology, Cancer Biology Division, School of Medicine; Washington University in St. Louis; St. Louis Missouri
| | - Irene M. Ghobrial
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
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Richardson PG, Bladé J. The comprehensive clinical management of multiple myeloma and related-plasma cell disorders. Expert Rev Hematol 2014; 7:1-3. [PMID: 24483345 DOI: 10.1586/17474086.2014.882763] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Whilst we think of multiple myeloma and related plasma cell disorders as incurable to date, never before has there been such hope and enthusiasm about advances in the research and treatment of these various diseases. Translational research is very much at the forefront of progress for further refining targeted therapies and continuing to improve clinical efficacy. Whilst some of these advances in the last decade have been truly dramatic in their scope and timing, it is also worth noting that relatively incremental changes have favorably impacted on patient outcome, and this comprehensive clinical management review captures these accordingly. We hope therefore that this concise overview will give readers, be they specialist hemato-oncologists, or other providers and researchers in the field, an enlightening insight into the exciting future of therapeutic opportunities, as well as a practical 'hands on' approach.
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Affiliation(s)
- Paul G Richardson
- RJ Corman Professor of Medicine, Harvard Medical School Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Multiple Myeloma Center, Boston, MA, USA
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