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Mainou M, Bougioukas KI, Malandris K, Liakos A, Klonizakis P, Avgerinos I, Haidich AB, Tsapas A. Reporting of adverse events of treatment interventions in multiple myeloma: an overview of systematic reviews. Ann Hematol 2023:10.1007/s00277-023-05517-7. [PMID: 37935924 DOI: 10.1007/s00277-023-05517-7] [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: 07/14/2023] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
The present study is an overview of systematic reviews focusing on adverse events of antimyeloma treatments. It provides a systematic description of adverse events as they are reported in the systematic reviews as well as a critical appraisal of included reviews. We conducted a comprehensive literature search in the most widely used electronic databases looking for systematic reviews that had an adverse event of an antimyeloma treatment intervention as primary outcome. Two independent reviewers conducted selection of included studies and data extraction on predesigned online forms and assessed study quality using AMSTAR 2. Overall corrected covered area (CCA) was calculated to examine the overlap of primary studies across systematic reviews. After screening eligible studies, 23 systematic reviews were included in this overview. Seven reviews with overall CCA of 14.7% examined cardiovascular adverse events of different drugs, including immunomodulatory drugs and proteasome inhibitors (mainly carfilzomib). Nine focused on infections, presenting with overall CCA of 5.8%, each one focused on a different drug or drug class. Three studied thromboembolism in patients treated either with lenalidomide, any immunomodulatory drug, or with daratumumab and had an overall CCA equal to 1.5%. Four more reviews focused on bortezomib-associated neurotoxicity, carfilzomib-associated renal toxicity, or second primary malignancies as an adverse event of lenalidomide or anti-CD38 monoclonal antibody treatment. The quality of included studies as judged by AMSTAR 2 was mostly critically low. Absence of a priori registered protocol and formal assessment of risk of bias of included primary studies were the most common shortcomings. Reporting of antimyeloma drug-associated toxicity is supported by multiple systematic reviews; nevertheless, methodological quality of existing reviews is mostly low.
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Affiliation(s)
- Maria Mainou
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Konstantinos I Bougioukas
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece
| | - Konstantinos Malandris
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aris Liakos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Philippos Klonizakis
- Adult Thalassemia Unit, Second Department of Internal Medicine, Hippokration Hospital, Thessaloniki, Greece
| | - Ioannis Avgerinos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna-Betinna Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece
| | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, UK
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Georgoulis V, Haidich AB, Bougioukas KI, Hatzimichael E. Efficacy and safety of carfilzomib for the treatment of multiple myeloma: An overview of systematic reviews. Crit Rev Oncol Hematol 2022; 180:103842. [DOI: 10.1016/j.critrevonc.2022.103842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/24/2022] Open
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Gandhi M, Bakhai V, Trivedi J, Mishra A, De Andrés F, LLerena A, Sharma R, Nair S. Current perspectives on interethnic variability in multiple myeloma: Single cell technology, population pharmacogenetics and molecular signal transduction. Transl Oncol 2022; 25:101532. [PMID: 36103755 PMCID: PMC9478452 DOI: 10.1016/j.tranon.2022.101532] [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: 03/31/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022] Open
Abstract
This review discusses the emerging single cell technologies and applications in Multiple myeloma (MM), population pharmacogenetics of MM, resistance to chemotherapy, genetic determinants of drug-induced toxicity, molecular signal transduction. The role(s) of epigenetics and noncoding RNAs including microRNAs (miRNAs) and long noncoding RNAs (lncRNAs) that influence the risk and severity of MM are also discussed. It is understood that ethnic component acts as a driver of variable response to chemotherapy in different sub-populations globally. This review augments our understanding of genetic variability in ‘myelomagenesis’ and drug-induced toxicity, myeloma microenvironment at the molecular and cellular level, and developing precision medicine strategies to combat this malignancy. The emerging single cell technologies hold great promise for enhancing our understanding of MM tumor heterogeneity and clonal diversity.
Multiple myeloma (MM) is an aggressive cancer characterised by malignancy of the plasma cells and a rising global incidence. The gold standard for optimum response is aggressive chemotherapy followed by autologous stem cell transplantation (ASCT). However, majority of the patients are above 60 years and this presents the clinician with complications such as ineligibility for ASCT, frailty, drug-induced toxicity and differential/partial response to treatment. The latter is partly driven by heterogenous genotypes of the disease in different subpopulations. In this review, we discuss emerging single cell technologies and applications in MM, population pharmacogenetics of MM, resistance to chemotherapy, genetic determinants of drug-induced toxicity, molecular signal transduction, as well as the role(s) played by epigenetics and noncoding RNAs including microRNAs (miRNAs) and long noncoding RNAs (lncRNAs) that influence the risk and severity of the disease. Taken together, our discussions further our understanding of genetic variability in ‘myelomagenesis’ and drug-induced toxicity, augment our understanding of the myeloma microenvironment at the molecular and cellular level and provide a basis for developing precision medicine strategies to combat this malignancy.
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Affiliation(s)
- Manav Gandhi
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd., Orlando, FL 32827, USA
| | - Viral Bakhai
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS University, V. L. Mehta Road, Vile Parle (West), Mumbai 400056, India
| | - Jash Trivedi
- University of Mumbai, Santa Cruz, Mumbai 400055, India
| | - Adarsh Mishra
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS University, V. L. Mehta Road, Vile Parle (West), Mumbai 400056, India
| | - Fernando De Andrés
- INUBE Extremadura Biosanitary Research Institute, Badajoz, Spain; Faculty of Medicine, University of Extremadura, Badajoz, Spain; CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Adrián LLerena
- INUBE Extremadura Biosanitary Research Institute, Badajoz, Spain; Faculty of Medicine, University of Extremadura, Badajoz, Spain; CICAB Clinical Research Center, Pharmacogenetics and Personalized Medicine Unit, Badajoz University Hospital, Extremadura Health Service, Badajoz, Spain
| | - Rohit Sharma
- Department of Rasa Shastra and Bhaishajya Kalpana, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh 221005, India.
| | - Sujit Nair
- University of Mumbai, Santa Cruz, Mumbai 400055, India.
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Terpos E, Stamatelopoulos K, Makris N, Georgiopoulos G, Ntanasis-Stathopoulos I, Gavriatopoulou M, Laina A, Eleutherakis-Papaiakovou E, Fotiou D, Kanellias N, Malandrakis P, Delialis D, Andreadou I, Kastritis E, Dimopoulos MA. Daratumumab May Attenuate Cardiac Dysfunction Related to Carfilzomib in Patients with Relapsed/Refractory Multiple Myeloma: A Prospective Study. Cancers (Basel) 2021; 13:cancers13205057. [PMID: 34680206 PMCID: PMC8533991 DOI: 10.3390/cancers13205057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 01/04/2023] Open
Abstract
Simple Summary The management of cardiovascular adverse events in patients with relapsed/refractory multiple myeloma undergoing treatment with carfilzomib can be challenging. Herein, we evaluated the potential cardioprotective effect of daratumumab when administered in combination with carfilzomib and dexamethasone (DaraKd). The study included 25 patients receiving either DaraKd (n = 14) or Kd (n = 11) who were evaluated for echocardiographic changes at the sixth cycle of treatment compared with baseline assessment. DaraKd was associated with preserved post-treatment cardiac systolic function compared with Kd. CD38 inhibition by daratumumab might restore metabolic disequilibrium in the cardiac tissue and prevent cardiac injury. A trend for a lower rate of cardiovascular adverse events among patients receiving DaraKd was also evident, although larger studies are needed to determine the association between echocardiographic and/or biomarker changes with cardiovascular adverse events. Abstract Carfilzomib has improved survival in patients with relapsed/refractory multiple myeloma (RRMM), but it may exert cardiovascular adverse events (CVAEs). The aim of this study was to assess whether treatment with daratumumab may ameliorate carfilzomib-related toxicity. We prospectively evaluated 25 patients with RRMM who received either daratumumab in combination with carfilzomib and dexamethasone (DaraKd) (n = 14) or Kd (n = 11). Cardiac ultrasound was performed before treatment initiation and C6D16 or at the time of treatment interruption. Patients were followed for a median of 10 months for CVAEs. The mean (± SD) age was 67.8 ± 7.6 years and 60% were men. The two treatment groups did not significantly differ in baseline demographic characteristics (p > 0.1 for all). In the DaraKd group, we did not observe any significant change in markers of ventricular systolic function. However, these markers deteriorated in the Kd group; left ventricular (LV) ejection fraction, LV global longitudinal strain, tricuspid annular plane systolic excursion and RV free wall longitudinal strain significantly decreased from baseline to second visit (p < 0.05). A significant group interaction (p < 0.05) was observed for the abovementioned changes. CVAEs occurred more frequently in the Kd than the DaraKd group (45% vs. 28.6%). DaraKd was associated with preserved post-treatment cardiac systolic function and lower CVAE rate compared with Kd. The clinical significance and the underlying mechanisms merit further investigation.
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Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
- Correspondence:
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Nikolaos Makris
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Georgios Georgiopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Ageliki Laina
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Evangelos Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Dimitris Delialis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, 15771 Athens, Greece;
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (K.S.); (N.M.); (G.G.); (I.N.-S.); (M.G.); (A.L.); (E.E.-P.); (D.F.); (N.K.); (P.M.); (D.D.); (E.K.); (M.A.D.)
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Proskuriakova E, Jada K, Kakieu Djossi S, Khedr A, Neupane B, Mostafa JA. Mechanisms and Potential Treatment Options of Heart Failure in Patients With Multiple Myeloma. Cureus 2021; 13:e15943. [PMID: 34336442 PMCID: PMC8312996 DOI: 10.7759/cureus.15943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/26/2021] [Indexed: 11/26/2022] Open
Abstract
Multiple myeloma is a pathology of plasma cells, with one of the most common side effects of its treatment is heart failure. In addition, cardiac amyloidosis could cause heart failure by itself. Even though mechanisms of cardiac amyloidosis are known, and they involve lysosomal dysfunction, reactive oxygen species (ROS) accumulation, and infiltrative effect by fibrils, there is no specific agent that could protect from these effects. While the molecular mechanism of doxorubicin cardiotoxicity via topoisomerase II β is established, the only FDA-approved agent for treatment is dexrazoxane. Liposomal doxorubicin can potentially improve response and decrease the development of heart failure due to microscopic liposomes that can accumulate and penetrate only tumor vasculature. Supplements that enhance mitochondrial biogenesis are also shown to improve doxorubicin-induced cardiotoxicity. Other agents, such as JR-311, ICRF-193, and ursolic acid, could potentially become new treatment options. Proteasome inhibitors, novel agents, have significantly improved survival rates among multiple myeloma patients. They act on a proteasome system that is highly active in cardiomyocytes and activates various molecular cascades in malignant cells, as well as in the heart, through nuclear factor kappa B (NF-kB), endoplasmic reticulum (ER), calcineurin-nuclear factor of activated T-cells (NFAT), and adenosine monophosphate-activated protein kinase (AMPKa)/autophagy pathways. Metformin, apremilast, and rutin have shown positive results in animal studies and may become a promising therapy as cardioprotective agents. This article aims to highlight the main molecular mechanisms of heart failure among patients with multiple myeloma and potential treatment options to facilitate the development and research of new preventive strategies. Hence, this will have a positive impact on life expectancy in patients with multiple myeloma.
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Affiliation(s)
- Ekaterina Proskuriakova
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Keji Jada
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Anwar Khedr
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bandana Neupane
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jihan A Mostafa
- Psychiatry, Psychotherapy and Research Field, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Bishnoi R, Xie Z, Shah C, Bian J, Murthy HS, Wingard JR, Farhadfar N. Real-world experience of carfilzomib-associated cardiovascular adverse events: SEER-Medicare data set analysis. Cancer Med 2021; 10:70-78. [PMID: 33169938 PMCID: PMC7826471 DOI: 10.1002/cam4.3568] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/23/2020] [Accepted: 10/05/2020] [Indexed: 01/08/2023] Open
Abstract
Carfilzomib was approved for the treatment of multiple myeloma in 2012 and since then there have been concerns for cardiovascular toxicity from its use. With this study, we aim to further study the hazards and underlying risk factors for cardiovascular adverse events associated with carfilzomib. This study was conducted using Surveillance, Epidemiology, and End Results (SEER)-Medicare data set of multiple myeloma from 2001 to 2015. Data were analyzed for hazards ratio of cardiovascular adverse events between carfilzomib users and nonusers. We identified 7330 patients with multiple myeloma of whom 815 were carfilzomib users. Carfilzomib users had a statistically significant hazard ratio of 1.41 with p < 0.0001 for all cardiovascular adverse events as compared to nonusers. Carfilzomib use was significantly associated with increased risk of heart failure (HR 1.47, p = 0.0002), ischemic heart disease (HR 1.45, p = 0.0002), and hypertension (HR 3.33, p < 0.0001), whereas there was no association between carfilzomib use and cardiac conduction disorders (arrhythmia and heart blocks). Carfilzomib users were at higher risk of new-onset edema (HR 5.09, p < 0.0001), syncope (HR 4.27, p < 0.0001), dyspnea (HR 1.33, p < 0.0001), and chest pain (HR 1.18, p < 0.0001) as compared to carfilzomib nonusers. Age above 75 years, preexisting cardiovascular disease, obesity, and twice a week carfilzomib schedule were significant risk factors associated with cardiovascular adverse events in carfilzomib users. The median time of the onset for all cardiovascular adverse events was 3.1 months. This study has identified a significantly higher likelihood of cardiovascular adverse events in elderly Medicare patients receiving carfilzomib.
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Affiliation(s)
- Rohit Bishnoi
- Division of Hematology and OncologyDepartment of MedicineUniversity of FloridaGainesvilleFLUSA
| | - Zhigang Xie
- Department of Health Services Research, Management and PolicyCollege of Public Health and Health ProfessionsUniversity of FloridaGainesvilleFLUSA
| | - Chintan Shah
- Division of Hematology and OncologyDepartment of MedicineUniversity of FloridaGainesvilleFLUSA
| | - Jiang Bian
- Department of Health Outcomes and BioinformaticsCollege of MedicineUniversity of FloridaGainesvilleFLUSA
| | - Hemant S. Murthy
- Division of Hematology/OncologyMayo Clinic Alix School of MedicineMayo Clinic FloridaJacksonvilleFLUSA
| | - John R. Wingard
- Bone Marrow Transplant ProgramUniversity of Florida Health Cancer CenterGainesvilleFLUSA
- Division of Hematology/OncologyUniversity of Florida College of MedicineGainesvilleFLUSA
| | - Nosha Farhadfar
- Division of Hematology/OncologyUniversity of Florida College of MedicineGainesvilleFLUSA
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Dasanu CA, Plaxe SC, Popescu IM, Gupta V, Sontz E, Codreanu I. Severe left atrial enlargement due to carfilzomib use in multiple myeloma. J Oncol Pharm Pract 2019; 25:2045-2048. [PMID: 30636528 DOI: 10.1177/1078155218825298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Several cardiovascular effects have been attributed to carfilzomib in the recent literature. These side effects must be recognized promptly by treating physicians and pharmacists. Special attention is required in patients with pre-existing cardiac conditions, liver function abnormalities and/or advanced age. This is the first report of a severe left atrial enlargement due to carfilzomib use in the setting of multiple myeloma. This condition improved dramatically seven months after cessation of carfilzomib. The authors discuss further various cardiac and vascular abnormalities linked with carfilzomib in the medical literature. Prompt withdrawal of this agent is essential in these cases as it may prevent dismal outcomes.
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Affiliation(s)
- Constantin A Dasanu
- Eisenhower Lucy Curci Cancer Center, Rancho Mirage, CA, USA.,University of California in San Diego Health System, San Diego, CA, USA
| | - Steven C Plaxe
- Eisenhower Lucy Curci Cancer Center, Rancho Mirage, CA, USA.,University of California in San Diego Health System, San Diego, CA, USA
| | - Iliana M Popescu
- Eisenhower Lucy Curci Cancer Center, Rancho Mirage, CA, USA.,University of California in San Diego Health System, San Diego, CA, USA
| | - Varun Gupta
- Eisenhower Lucy Curci Cancer Center, Rancho Mirage, CA, USA.,University of California in San Diego Health System, San Diego, CA, USA
| | - Eric Sontz
- Department of Cardiology, Eisenhower Medical Center, Rancho Mirage, CA, USA
| | - Ion Codreanu
- Department of Radiology and Imaging, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Moldova
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