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De Novellis D, Derudas D, Vincelli D, Fontana R, Della Pepa R, Palmieri S, Accardi F, Rotondo F, Morelli E, Gigliotta E, Roccotelli D, Marano L, Barone ML, Cetani G, Esposito D, Lazzaro A, Delle Cave G, Serio B, Morini D, Porrazzo M, Urciuoli E, Masucci C, Fanelli F, Rizzo M, Arcamone M, Trastulli F, Rocco S, Leone A, Bianco R, Salvatore F, Idato A, Sicari M, Tosi P, Rascato MG, Di Perna M, Falcone AP, Morello L, Carlisi M, Svanera G, Annunziata M, Frigeri F, Califano C, Carella AM, Marcacci G, Pane F, Risitano AM, Giudice V, Botta C, Selleri C. Clinical Efficacy of Isatuximab Plus Carfilzomib and Dexamethasone in Relapsed/Refractory Multiple Myeloma Patients. Eur J Haematol 2024. [PMID: 39370303 DOI: 10.1111/ejh.14314] [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: 07/23/2024] [Revised: 09/09/2024] [Accepted: 09/18/2024] [Indexed: 10/08/2024]
Abstract
Isatuximab, a novel anti-CD38 monoclonal antibody, is approved in combination with carfilzomib and dexamethasone (Isa-Kd) in relapsed/refractory multiple myeloma (RRMM) patients. Because of its recent introduction, real-world efficacy and safety are poorly reported. In this Italian multicenter real-life observational retrospective study, efficacy and safety of the Isa-Kd regimen were evaluated in a cohort of 103 RRMM patients. Overall response rate (ORR) was 85%, with stringent (sCR) or complete response (CR) in 18% of cases and very good partial response (VGPR) in 39%. Median PFS and OS were not reached within the study period, while 1-year PFS and OS were 72% and 77%, respectively. Hematological toxicities were observed in 42% of subjects, and cardiac toxicities occurred in 24% of cases. Moreover, we conducted a subanalysis on patients (N = 69) treated with Isa-Kd after one prior line of therapy, showing an ORR of 88%, with sCR + CR in 20% of subjects, VGPR in 46%, and PR in 22% of patients. In this group, median PFS and OS were not reached, while 1-year PFS and OS were 92% and 95%, respectively. In conclusions, our study confirmed Isa-Kd as an effective treatment option for RRMM with a manageable safety profile even in real-life settings.
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Affiliation(s)
- Danilo De Novellis
- Hematology and Transplant Center, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Daniele Derudas
- S.C. di Ematologia e C.T.M.O., Ospedale Oncologico di Riferimento Regionale "A. Businco", Cagliari, Italy
| | - Donatella Vincelli
- Division of Hematology, Azienda Ospedaliera "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Raffaele Fontana
- Hematology and Transplant Center, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Roberta Della Pepa
- Hematology - Department of Clinical Medicine and Surgery, University Hospital "Federico II", Naples, Italy
| | | | - Fabrizio Accardi
- U.O.C di Oncoematologia, Azienda Ospedaliera Ospedali Riuniti Villa Sofia - Cervello, Palermo, Italy
| | | | - Emanuela Morelli
- Hematology and Transplant Center, Istituto Nazionale Tumori, Fondazione "G.Pascale", IRRCS, Naples, Italy
| | - Emilia Gigliotta
- Dipartimento di Promozione della Salute, Materno-infantile, di medicina interna e specialistica d'eccellenza "G. D'alessandro", Università di Palermo, Palermo, Italy
| | - Daniela Roccotelli
- Division of Hematology and Stem Cell Unit, IRCCS S. Giovanni Rotondo and Division of Hematology, San Giovanni Rotondo, Italy
| | - Luana Marano
- Hematology, Hospital "San Giuseppe Moscati", Avellino, Italy
| | | | - Giusy Cetani
- Hematology, Hospital "Sant'Anna e San Sebastiano", Caserta, Italy
| | | | - Antonio Lazzaro
- UO di Ematologia e Centro Trapianti Midollo Osseo, Dipartimento di Oncoematologia Azienda Usl di Piacenza, Piacenza, Italy
| | | | - Bianca Serio
- Hematology and Transplant Center, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Denise Morini
- Hematology and Transplant Center, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Marika Porrazzo
- U.O.C di Oncoematologia, Azienda Ospedaliera Ospedali Riuniti Villa Sofia - Cervello, Palermo, Italy
| | | | - Chiara Masucci
- Hematology, Hospital "San Giuseppe Moscati", Avellino, Italy
| | - Fulvia Fanelli
- Hematology, Hospital "San Giuseppe Moscati", Avellino, Italy
| | - Michela Rizzo
- Hematology and Transplant Center, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Manuela Arcamone
- Hematology and Transplant Center, Istituto Nazionale Tumori, Fondazione "G.Pascale", IRRCS, Naples, Italy
| | | | - Stefano Rocco
- Hematology, Hospital "Antonio Cardarelli", Naples, Italy
| | - Aldo Leone
- Hematology - Department of Clinical Medicine and Surgery, University Hospital "Federico II", Naples, Italy
| | - Rosario Bianco
- Hematology, Hospital "Sant'Anna e San Sebastiano", Caserta, Italy
| | | | - Aurora Idato
- Division of Hematology, Azienda Ospedaliera "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Maria Sicari
- Division of Hematology, Azienda Ospedaliera "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Patrizia Tosi
- Hematology Unit, Infermi Hospital Rimini, Rimini, Italy
| | | | | | - Antonietta Pia Falcone
- Division of Hematology and Stem Cell Unit, IRCCS S. Giovanni Rotondo and Division of Hematology, San Giovanni Rotondo, Italy
| | - Lucia Morello
- UO di Ematologia e Centro Trapianti Midollo Osseo, Dipartimento di Oncoematologia Azienda Usl di Piacenza, Piacenza, Italy
| | - Melania Carlisi
- Dipartimento di Promozione della Salute, Materno-infantile, di medicina interna e specialistica d'eccellenza "G. D'alessandro", Università di Palermo, Palermo, Italy
| | - Gino Svanera
- Hematology, Hospital "San Giuliano", Giugliano, Italy
| | | | | | | | - Angelo Michele Carella
- Division of Hematology and Stem Cell Unit, IRCCS S. Giovanni Rotondo and Division of Hematology, San Giovanni Rotondo, Italy
| | - Gianpaolo Marcacci
- Hematology and Transplant Center, Istituto Nazionale Tumori, Fondazione "G.Pascale", IRRCS, Naples, Italy
| | - Fabrizio Pane
- Hematology - Department of Clinical Medicine and Surgery, University Hospital "Federico II", Naples, Italy
| | | | - Valentina Giudice
- Hematology and Transplant Center, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Ciro Botta
- Dipartimento di Promozione della Salute, Materno-infantile, di medicina interna e specialistica d'eccellenza "G. D'alessandro", Università di Palermo, Palermo, Italy
| | - Carmine Selleri
- Hematology and Transplant Center, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
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2
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Soloveva M, Solovev M, Risinskaya N, Nikulina E, Yakutik I, Biderman B, Obukhova T, Chabaeva Y, Kulikov S, Sudarikov A, Mendeleeva L. Loss of Heterozygosity and Mutations in the RAS-ERK Pathway Genes in Tumor Cells of Various Loci in Multiple Myeloma. Int J Mol Sci 2024; 25:9426. [PMID: 39273371 PMCID: PMC11394882 DOI: 10.3390/ijms25179426] [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: 07/15/2024] [Revised: 08/28/2024] [Accepted: 08/28/2024] [Indexed: 09/15/2024] Open
Abstract
Multiple myeloma (MM) is a disease characterized by spatiotemporal heterogeneity of tumor clones. Different genetic aberrations can be observed simultaneously in tumor cells from different loci, and as the disease progresses, new subclones may appear. The role of liquid biopsy, which is based on the analysis of tumor DNA circulating in the blood plasma, continues to be explored in MM. Here, we present an analysis of the STR profiles and mutation status of the KRAS, NRAS, and BRAF genes, evaluated in plasma free circulating tumor DNA (ctDNA), CD138+ bone marrow cells, and plasmacytomas. The prospective single-center study included 97 patients, with a median age of 55 years. Of these, 94 had newly diagnosed symptomatic MM, and three had primary plasma cell leukemia. It should be noted that if mutations were detected only in ctDNA, "non-classical" codons were more often affected. A variety of adverse laboratory and clinical factors have been associated with the detection of rare KRAS or NRAS gene mutations in bone marrow or ctDNA, suggesting that these mutations may be factors of an unfavorable prognosis for MM. Liquid biopsy studies provide undeniable fundamental information about tumor heterogeneity and clonal evolution in MM. Moreover, we focus on using liquid biopsy to identify new high-risk factors for MM.
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Affiliation(s)
- Maiia Soloveva
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Maksim Solovev
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Natalya Risinskaya
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Elena Nikulina
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Igor Yakutik
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Bella Biderman
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Tatiana Obukhova
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Yulia Chabaeva
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Sergej Kulikov
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Andrey Sudarikov
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
| | - Larisa Mendeleeva
- National Medical Research Center for Hematology, Novy Zykovski Lane, 4a, 125167 Moscow, Russia
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Fazio M, Sorbello CMC, Del Fabro V, Romano A, Cannizzaro MT, Parrinello NL, Esposito B, Frazzetto S, Elia F, Di Raimondo F, Conticello C. IgG-k/IgG-λ Para-Osseous Plasmacytoma Relapsed as Soft-Tissue Plasmacytoma with IgA-k Immunophenotype: A Case Report and Review of the Literature on Related Biochemical Aspects. Hematol Rep 2024; 16:541-551. [PMID: 39311139 PMCID: PMC11417817 DOI: 10.3390/hematolrep16030052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 08/06/2024] [Accepted: 08/26/2024] [Indexed: 09/26/2024] Open
Abstract
Neoplastic plasma cells (PCs) proliferation at anatomic sites dislocated from the bone marrow (BM) or their contiguous growth from osseous lesions that disrupt the cortical bone is termed extramedullary multiple myeloma (EMD). EMD still remains challenging from a therapeutic and biological perspective. Pathogenesis has not been completely clarified, and it is generally associated with high-risk cytogenetics (HRCAs). In order to emphasize the clinical and biochemical complexity of this disease, we have decided to describe the case of a patient affected by relapsed-refractory (RR) EMD, which presented as para-osseous plasmacytoma with a bi-phenotypical immunoglobulin (Ig) component and lately relapsed as soft-tissue plasmacytoma with a total immunophenotype switch. We have also hypothesized a correlation between Ig patterns and prognosis and suggested the possible inclusion of these biochemical features in the general risk assessment.
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Affiliation(s)
- Manlio Fazio
- Post-Graduation School of Haematology, University of Catania, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (C.M.C.S.); (B.E.); (F.D.R.)
- Division of Haematology and BMT, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (V.D.F.); (A.R.); (N.L.P.); (F.E.)
| | - Chiara Maria Catena Sorbello
- Post-Graduation School of Haematology, University of Catania, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (C.M.C.S.); (B.E.); (F.D.R.)
| | - Vittorio Del Fabro
- Division of Haematology and BMT, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (V.D.F.); (A.R.); (N.L.P.); (F.E.)
| | - Alessandra Romano
- Division of Haematology and BMT, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (V.D.F.); (A.R.); (N.L.P.); (F.E.)
- Dipartimento di Specialità Medico-Chirurgiche, Dipartimento di Chirurgia Generale e Specialità Medico-Chirurgiche, Sezione di Ematologia, Università degli Studi di Catania, 95131 Catania, Italy
| | | | - Nunziatina Laura Parrinello
- Division of Haematology and BMT, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (V.D.F.); (A.R.); (N.L.P.); (F.E.)
| | - Benedetta Esposito
- Post-Graduation School of Haematology, University of Catania, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (C.M.C.S.); (B.E.); (F.D.R.)
- Division of Haematology and BMT, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (V.D.F.); (A.R.); (N.L.P.); (F.E.)
| | - Sara Frazzetto
- Post-Graduation School of Haematology, University of Catania, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (C.M.C.S.); (B.E.); (F.D.R.)
| | - Federica Elia
- Division of Haematology and BMT, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (V.D.F.); (A.R.); (N.L.P.); (F.E.)
| | - Francesco Di Raimondo
- Post-Graduation School of Haematology, University of Catania, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (C.M.C.S.); (B.E.); (F.D.R.)
- Division of Haematology and BMT, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (V.D.F.); (A.R.); (N.L.P.); (F.E.)
- Radiology via Santa Sofia 78 AOU Policlinico—“Vittorio Emanuele”, 95123 Catania, Italy;
| | - Concetta Conticello
- Division of Haematology and BMT, A.O.U. ‘Policlinico-San Marco’, 95123 Catania, Italy; (V.D.F.); (A.R.); (N.L.P.); (F.E.)
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Bors A, Kozma A, Tomán Á, Őrfi Z, Kondor N, Tasnády S, Vályi-Nagy I, Reményi P, Mikala G, Andrikovics H. IGH::NSD2 Fusion Gene Transcript as Measurable Residual Disease Marker in Multiple Myeloma. Cancers (Basel) 2024; 16:283. [PMID: 38254774 PMCID: PMC10813871 DOI: 10.3390/cancers16020283] [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: 11/30/2023] [Revised: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Multiple myeloma (MM) is the second most common hematological malignancy. Approximately 15% of MM patients are affected by the t(4;14) translocation resulting in the IGH::NSD2 fusion transcript. Breakage occurs in three major breakpoint regions within the NSD2 gene (MB4-1, MB4-2, and MB4-3), where MB4-1 leads to the production of full-length protein, while truncated proteins are expressed in the other two cases. Measurable residual disease (MRD) has been conclusively established as a crucial prognostic factor in MM. The IGH::NSD2 fusion transcript can serve as a sensitive MRD marker. Using bone marrow (BM) and peripheral blood (PB) samples from 111 patients, we developed a highly sensitive quantitative real-time PCR (qPCR) and digital PCR (dPCR) system capable of detecting fusion mRNAs with a sensitivity of up to 1:100,000. PB samples exhibited sensitivity three orders of magnitude lower compared to BM samples. Patients with an MB4-2 breakpoint demonstrated significantly reduced overall survival (p = 0.003). Our novel method offers a simple and sensitive means for detecting MRD in a substantial proportion of MM patients. Monitoring may be carried out even from PB samples. The literature lacks consensus regarding survival outcomes among patients with different NSD2 breakpoints. Our data align with previous findings indicating that patients with the MB4-2 breakpoint type tend to exhibit unfavorable overall survival.
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Affiliation(s)
- András Bors
- Laboratory of Molecular Genetics, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (A.K.); (Á.T.); (Z.Ő.); (H.A.)
| | - András Kozma
- Laboratory of Molecular Genetics, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (A.K.); (Á.T.); (Z.Ő.); (H.A.)
| | - Ágnes Tomán
- Laboratory of Molecular Genetics, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (A.K.); (Á.T.); (Z.Ő.); (H.A.)
| | - Zoltán Őrfi
- Laboratory of Molecular Genetics, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (A.K.); (Á.T.); (Z.Ő.); (H.A.)
| | - Nóra Kondor
- Laboratory of Molecular Genetics, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (A.K.); (Á.T.); (Z.Ő.); (H.A.)
| | - Szabolcs Tasnády
- Department of Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (S.T.); (I.V.-N.); (P.R.); (G.M.)
| | - István Vályi-Nagy
- Department of Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (S.T.); (I.V.-N.); (P.R.); (G.M.)
| | - Péter Reményi
- Department of Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (S.T.); (I.V.-N.); (P.R.); (G.M.)
| | - Gábor Mikala
- Department of Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (S.T.); (I.V.-N.); (P.R.); (G.M.)
| | - Hajnalka Andrikovics
- Laboratory of Molecular Genetics, Central Hospital of Southern Pest-National Institute of Hematology and Infectious Disease, H-1097 Budapest, Hungary; (A.K.); (Á.T.); (Z.Ő.); (H.A.)
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Yanamandra U, Reddy Gorla AK, Agrawal K, Mittal BR, Prakash G, Khadwal AR, Varma N, Varma S, Malhotra P. Prognostic significance of extramedullary disease (EMD) detected on pre-transplant 18F-FDG PET/CT in patients with multiple myeloma: Results of PIPET-M trial. Med J Armed Forces India 2023; 79:672-678. [PMID: 37981939 PMCID: PMC10654356 DOI: 10.1016/j.mjafi.2023.08.007] [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: 06/18/2023] [Accepted: 08/11/2023] [Indexed: 11/21/2023] Open
Abstract
Background It is difficult to prognosticate the post-Autologous Stem Cell Transplant (ASCT) responses in multiple myeloma (MM) with the currently available prognostication models. 18F-FDGPET/CT has numerous advantages to prognosticate the post-transplant responses by assessing extramedullary disease (EMD) in addition to the extent of active disease. We aimed at identifying the prognostic value of EMD in predicting progression-free survival (PFS) and overall survival (OS). Methods This is a single centre prospective study from western India during a study period of 2014-2022 (with a median follow-up of patients of 6 years). All ASCT patients underwent 18F-FDG-PET/CT as part of pre-transplant workup. The conditioning and treatment protocols were not modified based on PET/CT findings. EMD on PET/CT was correlated with pre-transplant biochemical markers and post-ASCT survival/ progression (as defined by revised IMWG criteria). Statistical analysis was done using SPSS ver. 20. Results Patients with pre-ASCT EMD had a hazard-ratio for post-transplant all-cause mortality of 5.46 (p-0.045). Pre-transplant β2M and LDH were significantly higher in patients with EMD (p-0.036). The 6-year median OS in patients with and without EMD were 57.1%, and 80.6% respectively. Kaplan-Meier analysis showed poorer OS in patients with EMD χ2 (1-0.496, p-0.481). There was no significant difference in clinical or biochemical EFS among patients with EMD. Conclusion EMD detected on 18F-FDG-PET/CT has a higher hazard for mortality and is significantly correlated with pre-transplant higher β2M and LDH levels. Thus, EMD by pre-transplant 18F-FDG-PET/CT has a significant prognostic role.
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Affiliation(s)
- Uday Yanamandra
- Professor, Department of Internal Medicine, Armed Forces Medical College, Pune, India
| | - Arun Kumar Reddy Gorla
- Junior Consultant, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Kanhaiyalal Agrawal
- Associate Professor (Nuclear Medicine), All India Institute of Medical Sciences, Bhubaneshwar, India
| | - Bhagwant Rai Mittal
- Professor (Nuclear Medicine), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Gaurav Prakash
- Professor (Clinical Hematology & Medical Oncology), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Alka Rani Khadwal
- Professor (Clinical Hematology & Medical Oncology), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Neelam Varma
- Ex-Professor & Head (Hematology), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Subhash Varma
- Ex-Dean, Ex-Professor & Head (Internal Medicine), Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Pankaj Malhotra
- Professor & Head (Clinical Hematology & Medical Oncology), Post Graduate Institute of Medical Education & Research, Chandigarh, India
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