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Arslan Davulcu E, Oğuz MB, Kılıç E, Eşkazan AE. Treatment of anemia in myelofibrosis: focusing on novel therapeutic options. Expert Opin Investig Drugs 2024; 33:27-37. [PMID: 38073183 DOI: 10.1080/13543784.2023.2294324] [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: 07/08/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Myelofibrosis is a clonal myeloproliferative neoplasm associated with the proliferation of hematopoietic stem cells, increased bone marrow fibrosis, extramedullary hematopoiesis, hepatosplenomegaly, abnormal cytokine production, and constitutional symptoms. These and many other factors contribute to the development of anemia in myelofibrosis patients. AREAS COVERED This review summarizes novel and promising treatments for anemia in myelofibrosis including transforming growth factor-β inhibitors luspatercept and KER-050, JAK inhibitors momelotinib, pacritinib, and jaktinib, BET inhibitors pelabresib and ABBV-744, antifibrotic PRM-151, BCL2/BCL-XL inhibitor navitoclax, and telomerase inhibitor imetelstat. EXPERT OPINION Standard approaches to treat myelofibrosis-related anemia have limited efficacy and are associated with toxicity. New drugs have shown positive results in myelofibrosis-associated anemia when used alone or in combination.
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Affiliation(s)
- Eren Arslan Davulcu
- Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Hematology Clinic, University of Health Sciences, Istanbul, Turkey
| | - Merve Beyza Oğuz
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Emre Kılıç
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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Duminuco A, Chifotides HT, Giallongo S, Giallongo C, Tibullo D, Palumbo GA. ACVR1: A Novel Therapeutic Target to Treat Anemia in Myelofibrosis. Cancers (Basel) 2023; 16:154. [PMID: 38201581 PMCID: PMC10778144 DOI: 10.3390/cancers16010154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Activin receptor type I (ACVR1) is a transmembrane kinase receptor belonging to bone morphogenic protein receptors (BMPs). ACVR1 plays an important role in hematopoiesis and anemia via the BMP6/ACVR1/SMAD pathway, which regulates expression of hepcidin, the master regulator of iron homeostasis. Elevated hepcidin levels are inversely associated with plasma iron levels, and chronic hepcidin expression leads to iron-restricted anemia. Anemia is one of the hallmarks of myelofibrosis (MF), a bone marrow (BM) malignancy characterized by BM scarring resulting in impaired hematopoiesis, splenomegaly, and systemic symptoms. Anemia and red blood cell transfusions negatively impact MF prognosis. Among the approved JAK inhibitors (ruxolitinib, fedratinib, momelotinib, and pacritinib) for MF, momelotinib and pacritinib are preferably used in cytopenic patients; both agents are potent ACVR1 inhibitors that suppress hepcidin expression via the BMP6/ACVR1/SMAD pathway and restore iron homeostasis/erythropoiesis. In September 2023, momelotinib was approved as a treatment for patients with MF and anemia. Zilurgisertib (ACVR1 inhibitor) and DISC-0974 (anti-hemojuvelin monoclonal antibody) are evaluated in early phase clinical trials in patients with MF and anemia. Luspatercept (ACVR2B ligand trap) is assessed in transfusion-dependent MF patients in a registrational phase 3 trial. Approved ACVR1 inhibitors and novel agents in development are poised to improve the outcomes of anemic MF patients.
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Affiliation(s)
- Andrea Duminuco
- Hematology Unit with BMT, A.O.U. Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy;
| | - Helen T. Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Blvd., Houston, TX 77030, USA;
| | - Sebastiano Giallongo
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (S.G.); (C.G.)
| | - Cesarina Giallongo
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (S.G.); (C.G.)
| | - Daniele Tibullo
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy;
| | - Giuseppe A. Palumbo
- Hematology Unit with BMT, A.O.U. Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy;
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (S.G.); (C.G.)
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Hsu CC, Senussi NH, Fertrin KY, Kowdley KV. Iron overload disorders. Hepatol Commun 2022; 6:1842-1854. [PMID: 35699322 PMCID: PMC9315134 DOI: 10.1002/hep4.2012] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/06/2022] [Accepted: 04/16/2022] [Indexed: 01/19/2023] Open
Abstract
Iron overload disorders represent a variety of conditions that lead to increased total body iron stores and resultant end-organ damage. An elevated ferritin and transferrin-iron saturation can be commonly encountered in the evaluation of elevated liver enzymes. Confirmatory homeostatic iron regulator (HFE) genetic testing for C282Y and H63D, mutations most encountered in hereditary hemochromatosis, should be pursued in evaluation of hyperferritinemia. Magnetic resonance imaging with quantitative assessment of iron content or liver biopsy (especially if liver disease is a cause of iron overload) should be used as appropriate. A secondary cause for iron overload should be considered if HFE genetic testing is negative for the C282Y homozygous or C282Y/H63D compound heterozygous mutations. Differential diagnosis of secondary iron overload includes hematologic disorders, iatrogenic causes, or chronic liver diseases. More common hematologic disorders include thalassemia syndromes, myelodysplastic syndrome, myelofibrosis, sideroblastic anemias, sickle cell disease, or pyruvate kinase deficiency. If iron overload has been excluded, evaluation for causes of hyperferritinemia should be pursued. Causes of hyperferritinemia include chronic liver disease, malignancy, infections, kidney failure, and rheumatic conditions, such as adult-onset Still's disease or hemophagocytic lymphohistiocytosis. In this review, we describe the diagnostic testing of patients with suspected hereditary hemochromatosis, the evaluation of patients with elevated serum ferritin levels, and signs of secondary overload and treatment options for those with secondary iron overload.
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Affiliation(s)
- Christine C Hsu
- Medstar Georgetown University HospitalMedstar Georgetown Transplant InstituteWashingtonDistrict of ColumbiaUSA
| | - Nizar H Senussi
- Gastroenterology and HepatologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Kleber Y Fertrin
- Division of HematologyDepartment of MedicineUniversity of WashingtonWashingtonUSA
| | - Kris V Kowdley
- Liver Institute Northwest and Elson S. Floyd College of MedicineWashington State UniversityWashingtonUSA
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Elli EM, Di Veroli A, Bartoletti D, Iurlo A, Carmosino I, Benevolo G, Abruzzese E, Bonifacio M, Bergamaschi M, Polverelli N, Caramella M, Cilloni D, Tiribelli M, Pugliese N, Caocci G, Crisà E, Porrini R, Markovic U, Renso R, Auteri G, Cattaneo D, Trawinska MM, Scaffidi L, Biale L, Bucelli C, Breccia M, Gambacorti-Passerini C, Palumbo GA, Latagliata R, Palandri F. Deferasirox in the management of iron overload in patients with myelofibrosis treated with ruxolitinib: The multicentre retrospective RUX-IOL study. Br J Haematol 2022; 197:190-200. [PMID: 35137397 DOI: 10.1111/bjh.18057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/10/2022] [Indexed: 12/11/2022]
Abstract
Deferasirox (DFX) is used for the management of iron overload (IOL) in many haematological malignancies including myelofibrosis (MF). The 'RUX-IOL' study retrospectively collected 69 MF patients treated with ruxolitinib (RUX) and DFX for IOL to assess: safety, efficacy in term of iron chelation response (ICR) and erythroid response (ER), and impact on overall survival of the combination therapy. The RUX-DFX therapy was administered for a median time of 12.4 months (interquartile range 3.1-71.2). During treatment, 36 (52.2%) and 34 (49.3%) patients required RUX and DFX dose reductions, while eight (11.6%) and nine (13.1%) patients discontinued due to RUX- or DFX-related adverse events; no unexpected toxicity was reported. ICR and ER were achieved by 33 (47.8%) and 32 patients (46.4%) respectively. Thirteen (18.9%) patients became transfusion-independent. Median time to ICR and ER was 6.2 and 2 months respectively. Patients achieving an ER were more likely to obtain an ICR also (p = 0.04). In multivariable analysis, the absence of leukocytosis at baseline (p = 0.02) and achievement of an ICR at any time (p = 0.02) predicted improved survival. In many MF patients, the RUX-DFX combination provided ICR and ER responses that correlated with improved outcome in the absence of unexpected toxicities. This strategy deserves further clinical investigation.
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Affiliation(s)
- Elena Maria Elli
- Hematology Division and Bone Marrow Unit, Ospedale San Gerardo, Monza, Italy
| | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia 'Seràgnoli', Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ida Carmosino
- Hematology, Department of Translational and Precision Medicine, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Giulia Benevolo
- Division of Haematology, Città della Salute e della Scienza Hospital, Turin, Italy
| | | | | | - Micaela Bergamaschi
- Medicina Interna PO ponente, Ospedale Santa Corona Pietra Ligure, Savona, Italy
| | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Marianna Caramella
- Division of Haematology, ASST Grande Ospedale Metropolitano, Niguarda, Milan, Italy
| | - Daniela Cilloni
- Haematology Division, Department of Clinical and Biological Sciences, Ospedale San Luigi di Orbassano, University of Turin, Orbassano, Italy
| | - Mario Tiribelli
- Division of Haematology and BMT, Department of Medical Area and Azienda Ospedaliero-Universitaria Friuli Centrale, Udine, Italy
| | - Novella Pugliese
- Department of Clinical Medicine and Surgery, Haematology Section, University of Naples 'Federico II', Naples, Italy
| | - Giovanni Caocci
- Ematologia, Ospedale Businco, Università degli studi di Cagliari, Cagliari, Italy
| | - Elena Crisà
- Division of Haematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | | | - Uros Markovic
- Hematology Division, AOU Policlinico 'G. Rodolico' - San Marco, Catania, Italy
| | - Rossella Renso
- Hematology Division and Bone Marrow Unit, Ospedale San Gerardo, Monza, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia 'Seràgnoli', Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Luigi Scaffidi
- Department of Medicine, Section of Haematology, University of Verona, Verona, Italy
| | - Lucia Biale
- Banca del Sangue, Servizio di Immunoematologia, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Policlinico Umberto I, Sapienza University, Rome, Italy
| | | | - Giuseppe Alberto Palumbo
- Department of Scienze Mediche, Chirurgiche e Tecnologie Avanzate 'G.F. Ingrassia', University of Catania, Catania, Italy
| | | | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia 'Seràgnoli', Bologna, Italy
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How We Manage Myelofibrosis Candidates for Allogeneic Stem Cell Transplantation. Cells 2022; 11:cells11030553. [PMID: 35159362 PMCID: PMC8834299 DOI: 10.3390/cells11030553] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 02/01/2023] Open
Abstract
Moving from indication to transplantation is a critical process in myelofibrosis. Most of guidelines specifically focus on either myelofibrosis disease or transplant procedure, and, currently, no distinct indication for the management of MF candidates to transplant is available. Nevertheless, this period of time is crucial for the transplant outcome because engraftment, non-relapse mortality, and relapse incidence are greatly dependent upon the pre-transplant management. Based on these premises, in this review, we will go through the path of identification of the MF patients suitable for a transplant, by using disease-specific prognostic scores, and the evaluation of eligibility for a transplant, based on performance, comorbidity, and other combined tools. Then, we will focus on the process of donor and conditioning regimens’ choice. The pre-transplant management of splenomegaly and constitutional symptoms, cytopenias, iron overload and transplant timing will be comprehensively discussed. The principal aim of this review is, therefore, to give a practical guidance for managing MF patients who are potential candidates for allo-HCT.
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Palumbo GA, Galimberti S, Barcellini W, Cilloni D, Di Renzo N, Elli EM, Finelli C, Maurillo L, Ricco A, Musto P, Russo R, Latagliata R. From Biology to Clinical Practice: Iron Chelation Therapy With Deferasirox. Front Oncol 2021; 11:752192. [PMID: 34692534 PMCID: PMC8527180 DOI: 10.3389/fonc.2021.752192] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/08/2021] [Indexed: 01/19/2023] Open
Abstract
Iron chelation therapy (ICT) has become a mainstay in heavily transfused hematological patients, with the aim to reduce iron overload (IOL) and prevent organ damage. This therapeutic approach is already widely used in thalassemic patients and in low-risk Myelodysplastic Syndrome (MDS) patients. More recently, ICT has been proposed for high-risk MDS, especially when an allogeneic bone marrow transplantation has been planned. Furthermore, other hematological and hereditary disorders, characterized by considerable transfusion support to manage anemia, could benefit from this therapy. Meanwhile, data accumulated on how iron toxicity could exacerbate anemia and other clinical comorbidities due to oxidative stress radical oxygen species (ROS) mediated by free iron species. Taking all into consideration, together with the availability of approved oral iron chelators, we envision a larger use of ICT in the near future. The aim of this review is to better identify those non-thalassemic patients who can benefit from ICT and give practical tips for management of this therapeutic strategy.
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Affiliation(s)
- Giuseppe A Palumbo
- Department of Scienze Mediche Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia, " University of Catania, Catania, Italy
| | - Sara Galimberti
- Section of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Wilma Barcellini
- Hematology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico di Milano and University of Milan, Milan, Italy
| | - Daniela Cilloni
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Nicola Di Renzo
- Hematology and Transplant Unit, Ospedale Vito Fazzi, Lecce, Italy
| | - Elena Maria Elli
- Division of Hematology and Bone Marrow Unit, Ospedale San Gerardo, Aziende Socio Sanitarie Territoriali (ASST), Monza, Italy
| | - Carlo Finelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Luca Maurillo
- Department of Onco-hematology, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Alessandra Ricco
- Unit of Hematology and Stem Cell Transplantation, Azienda Ospedaliera Universitaria (AOU) Consorziale Policlinico, Bari, Italy
| | - Pellegrino Musto
- Unit of Hematology and Stem Cell Transplantation, Azienda Ospedaliera Universitaria (AOU) Consorziale Policlinico, Bari, Italy.,Department of Emergency and Organ Transplantation, "Aldo Moro" University School of Medicine, Bari, Italy
| | - Rodolfo Russo
- Clinica Nefrologica, Dialisi e Trapianto, Department of Integrated Medicine with the Territory, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Roberto Latagliata
- Unità Operativa Complessa (UOC) Ematologia, Ospedale Belcolle, Viterbo and Division of Cellular Biotechnology and Hematology, Sapienza University, Rome, Italy
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Management of Myelofibrosis-Associated Anemia: Focus on Standard Agents and Novel Therapeutics in Phase 3 Clinical Trials. Curr Hematol Malig Rep 2021; 16:483-489. [PMID: 34499329 DOI: 10.1007/s11899-021-00651-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The management of myelofibrosis is risk-adapted when considering transplant eligibility and symptom-directed, prioritizing the most burdensome symptoms for the patient. Unfortunately, myelofibrosis-anemia is common, multifactorial in its origin, and impactful regarding prognosis. While clinical trials are advised, not all patients have convenient access, and therefore, hematologists should be aware of the data supporting the use of conventional agents such as erythropoietin-stimulating agents, steroid treatments (danazol and prednisone), and immunomodulatory drugs (thalidomide and lenalidomide). This review summarizes the conventional approach to treating myelofibrosis-anemia and highlights recent data from 3 novel agents that are under phase 3 evaluation. RECENT FINDINGS Momelotonib is a JAK1/2 and ACVR1 inhibitor that has demonstrated not only improvements in splenomegaly and symptoms, but also amelioration of anemia on the SIMPLIFY 1 and 2 clinical trial program. This may occur through suppression of hepcidin production. Luspatercept promotes late-stage hematopoiesis, and the phase 2 study has shown promise in ameliorating anemia as a monotherapy, and especially in combination with ruxolitinib. Finally, CP-0160, a BET inhibitor, has shown efficacy as an anemia-directed agent, when used as monotherapy and in combination. This agent reduces cytokine production and promotes erythroid differentiation. Results have been presented for patients previously treated with JAK inhibitors, as well as those who were naïve to JAK inhibitor therapy. Safety and effectiveness are reviewed for both conventional and selected novel agents used in the treatment of MF-anemia. A practical approach to treatment is presented, and data from ASH 2020 are presented.
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Barraco D, Maffioli M, Passamonti F. Standard care and investigational drugs in the treatment of myelofibrosis. Drugs Context 2019; 8:212603. [PMID: 31645880 PMCID: PMC6788389 DOI: 10.7573/dic.212603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 01/07/2023] Open
Abstract
Myelofibrosis (MF) is a heterogeneous disorder characterized by splenomegaly, constitutional symptoms, ineffective hematopoiesis, and an increased risk of leukemic transformation. The ongoing research in understanding the pathophysiology of the disease has allowed for the development of targeted drugs optimizing patient management. Furthermore, disease prognostication has significantly improved. Current therapeutic interventions are only partially effective with only allogeneic stem cell transplant potentially curative. Ruxolitinib is the only approved therapy for MF by the US Food and Drug Administration. However, despite efficacy in reducing splenomegaly and controlling symptomatology, it is not associated with consistent molecular or pathologic responses. Drug discontinuation is associated with a dismal outcome. The therapeutic landscape in MF has significantly improved, and emerging drugs with different target pathways, alone or in combination with ruxolitinib, seem promising.
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Affiliation(s)
- Daniela Barraco
- Hematology, Department of Specialistic Medicine, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
| | - Margherita Maffioli
- Hematology, Department of Specialistic Medicine, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
| | - Francesco Passamonti
- Hematology, Department of Specialistic Medicine, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
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