1
|
Wäsch R, Engelhardt M. In search for cure of multiple myeloma. Haematologica 2024; 109:1320-1322. [PMID: 37981890 PMCID: PMC11063856 DOI: 10.3324/haematol.2023.284292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/08/2023] [Indexed: 11/21/2023] Open
Abstract
Not available.
Collapse
Affiliation(s)
- Ralph Wäsch
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg.
| | - Monika Engelhardt
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg
| |
Collapse
|
2
|
Kozalak G, Koşar A. Autophagy-related mechanisms for treatment of multiple myeloma. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2023; 6:838-857. [PMID: 38239705 PMCID: PMC10792488 DOI: 10.20517/cdr.2023.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/12/2023] [Accepted: 12/20/2023] [Indexed: 01/22/2024]
Abstract
Multiple myeloma (MM) is a type of hematological cancer that occurs when B cells become malignant. Various drugs such as proteasome inhibitors, immunomodulators, and compounds that cause DNA damage can be used in the treatment of MM. Autophagy, a type 2 cell death mechanism, plays a crucial role in determining the fate of B cells, either promoting their survival or inducing cell death. Therefore, autophagy can either facilitate the progression or hinder the treatment of MM disease. In this review, autophagy mechanisms that may be effective in MM cells were covered and evaluated within the contexts of unfolded protein response (UPR), bone marrow microenvironment (BMME), drug resistance, hypoxia, DNA repair and transcriptional regulation, and apoptosis. The genes that are effective in each mechanism and research efforts on this subject were discussed in detail. Signaling pathways targeted by new drugs to benefit from autophagy in MM disease were covered. The efficacy of drugs that regulate autophagy in MM was examined, and clinical trials on this subject were included. Consequently, among the autophagy mechanisms that are effective in MM, the most suitable ones to be used in the treatment were expressed. The importance of 3D models and microfluidic systems for the discovery of new drugs for autophagy and personalized treatment was emphasized. Ultimately, this review aims to provide a comprehensive overview of MM disease, encompassing autophagy mechanisms, drugs, clinical studies, and further studies.
Collapse
Affiliation(s)
- Gül Kozalak
- Faculty of Engineering and Natural Science, Sabancı University, Istanbul 34956, Turkey
- Center of Excellence for Functional Surfaces and Interfaces for Nano Diagnostics (EFSUN), Sabancı University, Istanbul 34956, Turkey
| | - Ali Koşar
- Faculty of Engineering and Natural Science, Sabancı University, Istanbul 34956, Turkey
- Center of Excellence for Functional Surfaces and Interfaces for Nano Diagnostics (EFSUN), Sabancı University, Istanbul 34956, Turkey
- Turkish Academy of Sciences (TÜBA), Çankaya, Ankara 06700, Turkey
| |
Collapse
|
3
|
Ferro A, Pantazaka E, Athanassopoulos CM, Cuendet M. Histone deacetylase-based dual targeted inhibition in multiple myeloma. Med Res Rev 2023; 43:2177-2236. [PMID: 37191917 DOI: 10.1002/med.21972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 04/08/2023] [Accepted: 04/30/2023] [Indexed: 05/17/2023]
Abstract
Despite enormous advances in terms of therapeutic strategies, multiple myeloma (MM) still remains an incurable disease with MM patients often becoming resistant to standard treatments. To date, multiple combined and targeted therapies have proven to be more beneficial compared to monotherapy approaches, leading to a decrease in drug resistance and an improvement in median overall survival in patients. Moreover, recent breakthroughs highlighted the relevant role of histone deacetylases (HDACs) in cancer treatment, including MM. Thus, the simultaneous use of HDAC inhibitors with other conventional regimens, such as proteasome inhibitors, is of interest in the field. In this review, we provide a general overview of HDAC-based combination treatments in MM, through a critical presentation of publications from the past few decades related to in vitro and in vivo studies, as well as clinical trials. Furthermore, we discuss the recent introduction of dual-inhibitor entities that could have the same beneficial effects as drug combinations with the advantage of having two or more pharmacophores in one molecular structure. These findings could represent a starting-point for both reducing therapeutic doses and lowering the risk of developing drug resistance.
Collapse
Affiliation(s)
- Angelica Ferro
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Evangelia Pantazaka
- Synthetic Organic Chemistry Laboratory, Department of Chemistry, University of Patras, Patras, Greece
- Laboratory of Biochemistry/Metastatic Signaling, Section of Genetics, Cell Biology, and Development, Department of Biology, University of Patras, Patras, Greece
| | | | - Muriel Cuendet
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| |
Collapse
|
4
|
Mattioli R, Ilari A, Colotti B, Mosca L, Fazi F, Colotti G. Doxorubicin and other anthracyclines in cancers: Activity, chemoresistance and its overcoming. Mol Aspects Med 2023; 93:101205. [PMID: 37515939 DOI: 10.1016/j.mam.2023.101205] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023]
Abstract
Anthracyclines have been important and effective treatments against a number of cancers since their discovery. However, their use in therapy has been complicated by severe side effects and toxicity that occur during or after treatment, including cardiotoxicity. The mode of action of anthracyclines is complex, with several mechanisms proposed. It is possible that their high toxicity is due to the large set of processes involved in anthracycline action. The development of resistance is a major barrier to successful treatment when using anthracyclines. This resistance is based on a series of mechanisms that have been studied and addressed in recent years. This work provides an overview of the anthracyclines used in cancer therapy. It discusses their mechanisms of activity, toxicity, and chemoresistance, as well as the approaches used to improve their activity, decrease their toxicity, and overcome resistance.
Collapse
Affiliation(s)
- Roberto Mattioli
- Dept. Biochemical Sciences A. Rossi Fanelli, Sapienza University of Rome, Rome, Italy
| | - Andrea Ilari
- Institute of Molecular Biology and Pathology, Italian National Research Council IBPM-CNR, Rome, Italy
| | - Beatrice Colotti
- Dept. Biochemical Sciences A. Rossi Fanelli, Sapienza University of Rome, Rome, Italy
| | - Luciana Mosca
- Dept. Biochemical Sciences A. Rossi Fanelli, Sapienza University of Rome, Rome, Italy
| | - Francesco Fazi
- Department of Anatomical, Histological, Forensic & Orthopaedic Sciences, Section of Histology and Medical Embryology, Sapienza University of Rome, Rome, Italy
| | - Gianni Colotti
- Institute of Molecular Biology and Pathology, Italian National Research Council IBPM-CNR, Rome, Italy.
| |
Collapse
|
5
|
Kamens JL, Nance S, Koss C, Xu B, Cotton A, Lam JW, Garfinkle EAR, Nallagatla P, Smith AMR, Mitchell S, Ma J, Currier D, Wright WC, Kavdia K, Pagala VR, Kim W, Wallace LM, Cho JH, Fan Y, Seth A, Twarog N, Choi JK, Obeng EA, Hatley ME, Metzger ML, Inaba H, Jeha S, Rubnitz JE, Peng J, Chen T, Shelat AA, Guy RK, Gruber TA. Proteasome inhibition targets the KMT2A transcriptional complex in acute lymphoblastic leukemia. Nat Commun 2023; 14:809. [PMID: 36781850 PMCID: PMC9925443 DOI: 10.1038/s41467-023-36370-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/26/2023] [Indexed: 02/15/2023] Open
Abstract
Rearrangments in Histone-lysine-N-methyltransferase 2A (KMT2Ar) are associated with pediatric, adult and therapy-induced acute leukemias. Infants with KMT2Ar acute lymphoblastic leukemia (ALL) have a poor prognosis with an event-free-survival of 38%. Herein we evaluate 1116 FDA approved compounds in primary KMT2Ar infant ALL specimens and identify a sensitivity to proteasome inhibition. Upon exposure to this class of agents, cells demonstrate a depletion of histone H2B monoubiquitination (H2Bub1) and histone H3 lysine 79 dimethylation (H3K79me2) at KMT2A target genes in addition to a downregulation of the KMT2A gene expression signature, providing evidence that it targets the KMT2A transcriptional complex and alters the epigenome. A cohort of relapsed/refractory KMT2Ar patients treated with this approach on a compassionate basis had an overall response rate of 90%. In conclusion, we report on a high throughput drug screen in primary pediatric leukemia specimens whose results translate into clinically meaningful responses. This innovative treatment approach is now being evaluated in a multi-institutional upfront trial for infants with newly diagnosed ALL.
Collapse
Affiliation(s)
- Jennifer L Kamens
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie Nance
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Cary Koss
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Beisi Xu
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Anitria Cotton
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeannie W Lam
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Pratima Nallagatla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Amelia M R Smith
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Sharnise Mitchell
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jing Ma
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Duane Currier
- Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - William C Wright
- Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kanisha Kavdia
- Center for Proteomics and Metabolomics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Vishwajeeth R Pagala
- Center for Proteomics and Metabolomics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wonil Kim
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - LaShanale M Wallace
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ji-Hoon Cho
- Center for Proteomics and Metabolomics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yiping Fan
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Aman Seth
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nathaniel Twarog
- Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - John K Choi
- Department of Pathology, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Esther A Obeng
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mark E Hatley
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Monika L Metzger
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeffrey E Rubnitz
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Junmin Peng
- Center for Proteomics and Metabolomics, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Structural Biology, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Developmental Neurobiology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Taosheng Chen
- Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Anang A Shelat
- Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - R Kiplin Guy
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, KY, USA
| | - Tanja A Gruber
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA. .,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA.
| |
Collapse
|
6
|
Recent Advances in the Applications of Small Molecules in the Treatment of Multiple Myeloma. Int J Mol Sci 2023; 24:ijms24032645. [PMID: 36768967 PMCID: PMC9917049 DOI: 10.3390/ijms24032645] [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: 11/22/2022] [Revised: 01/15/2023] [Accepted: 01/24/2023] [Indexed: 02/01/2023] Open
Abstract
Therapy for multiple myeloma (MM), a hematologic neoplasm of plasma cells, has undergone remarkable changes over the past 25 years. Small molecules (molecular weight of less than one kDa), together with newer immunotherapies that include monoclonal antibodies, antibody-drug conjugates, and most recently, chimeric antigen receptor (CAR) T-cells, have combined to double the disease's five-year survival rate to over 50% during the past few decades. Despite these advances, the disease is still considered incurable, and its treatment continues to pose substantial challenges, since therapeutic refractoriness and patient relapse are exceedingly common. This review focuses on the current pipeline, along with the contemporary roles and future prospects for small molecules in MM therapy. While small molecules offer prospective benefits in terms of oral bioavailability, cellular penetration, simplicity of preparation, and improved cost-benefit considerations, they also pose problems of toxicity due to off-target effects. Highlighted in the discussion are recent developments in the applications of alkylating agents, immunomodulators, proteasome inhibitors, apoptosis inducers, kinesin spindle protein inhibitors, blockers of nuclear transport, and drugs that affect various kinases involved in intracellular signaling pathways. Molecular and cellular targets are described for each class of agents in relation to their roles as drivers of MM.
Collapse
|
7
|
Mian H, McCurdy A, Giri S, Grant S, Rochwerg B, Winks E, Rosko AE, Engelhardt M, Pawlyn C, Cook G, Jackson G, Bringhen S, Facon T, Larocca A, Zweegman S, Wildes TM. The prevalence and outcomes of frail older adults in clinical trials in multiple myeloma: A systematic review. Blood Cancer J 2023; 13:6. [PMID: 36599867 DOI: 10.1038/s41408-022-00779-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023] Open
Abstract
Multiple myeloma (MM) is an incurable blood cancer that primarily affects older adults. Several frailty tools have been developed to address the heterogeneity of aging in this population. Uptake of these measures has been variable, leading to a gap in knowledge regarding the proportion of enrolled trial participants considered frail and uncertainty in the treatment-related effects and outcomes among this high-risk population. We performed a systematic review of therapeutic interventional MM clinical trials reporting on frailty. We included 43 clinical trials (24 randomized controlled trials and 19 non-randomized trials) which met eligibility criteria. Frailty was increasingly incorporated in studies in more recent years with 41.9% of included studies being reported in the last two years. Commonly used frailty tools included the International Myeloma Working Group (IMWG) frailty index (41.8%), and the simplified frailty score (39.5%). Frailty status was categorized with 3 levels as (frail, intermediate fit, or fit) in 51.2% of the studies and dichotomized (frail, non-frail) in 18.6% of studies. Frailty prevalence greatly varied across trials ranging from 17.2% to 73.6% of the cohort. Of the included studies, 72.0% conducted subgroup analysis (planned or post-hoc) based on frailty status. Most studies demonstrated a consistent benefit of MM interventions among the frail and non-frail populations, however in general, frail patients had worse outcomes compared to the fit. Although frailty is increasingly being incorporated in MM clinical trials, due to the variation in both the definition and categorization of frailty, there remains heterogeneity in the prevalence of frailty and its potential associated impact on outcomes.
Collapse
Affiliation(s)
- Hira Mian
- Department of Oncology, McMaster University, Hamilton, ON, Canada.
| | - Arleigh McCurdy
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Smith Giri
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shakira Grant
- Department of Medicine, Division of Hematology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Erica Winks
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Ashley E Rosko
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Monika Engelhardt
- Hematology and Oncology Department, Interdisciplinary Cancer Center (ITZ) and Comprehensive Cancer Center Freiburg (CCCF), Faculty of Freidburg, University of Freiburg, Hugstetterstr. 53, 79106, Freiburg, Germany
| | - Charlotte Pawlyn
- The Institute of Cancer Research and Royal Marsden Hospital NHS Foundation Trust, London, UK
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Gordon Cook
- Cancer Research UK Clinical Trials Unit, LICTR, University of Leeds, Leeds, UK
| | - Graham Jackson
- Northern Centre for Cancer Care, Newcastle Upon Tyne Hospitals Trust, Newcastle Upon Tyne, UK
| | - Sara Bringhen
- SSD Clinical Trial in Onco-hematology and Multiple Myeloma, AOU City of Health and Science of Turin, Torino, Italy
| | - Thierry Facon
- University of Lille, CHU Lille, Service des Maladies du Sang, Lille, France
- French Academy of Medicine, Paris, France
| | - Alessandra Larocca
- SSD Clinical trials in onco-ematologia e mieloma multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Tanya M Wildes
- Division of Hematology/Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
8
|
Scheubeck S, Ihorst G, Schoeller K, Holler M, Möller MD, Reinhardt H, Wäsch R, Engelhardt M. Comparison of the prognostic significance of 5 comorbidity scores and 12 functional tests in a prospective multiple myeloma patient cohort. Cancer 2021; 127:3422-3436. [PMID: 34061991 DOI: 10.1002/cncr.33658] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Because of the various therapeutic options available for multiple myeloma (MM), remarkable interest exists today in individualized therapeutic concepts based on patients' fitness. The main objectives of this study were to compare different comorbidity scores and functional tests with respect to their impact on survival (overall survival [OS] and progression-free survival [PFS]); develop a time-efficient, MM-specific functional assessment (FA); and evaluate changes in patients' FA during treatment. METHODS The authors performed a prospective FA in 266 consecutive patients with MM at their initial diagnosis. This included 5 comorbidity scores and 12 commonly used geriatric functional tests. To evaluate changes in the course of treatment, the authors reassessed these 17 tests after ≥6 months. The entire analysis included 7327 FA tests. RESULTS On the basis of univariate and multivariate Cox regression analyses, the authors identified 4 of the 17 evaluated scores and functional tests as most relevant: the Revised Myeloma Comorbidity Index (R-MCI), Activity of Daily Living (ADL), the Mini-Mental State Examination (MMSE), and the quality-of-life 12-Item Short Form Health Survey Physical Composite Scale (SF-12 PCS). These showed precise group differences for fit, (intermediate-fit), and frail patients in OS and PFS: the 3-year OS rates were 90%, 74%, and 43% via the R-MCI for fit, intermediate-fit, and frail patients, respectively (P = .0006); 80% and 66% via the ADL for fit and frail patients, respectively (P = .0159); 78% and 48% via the MMSE for fit and frail patients, respectively (P = .0001); and 86% and 66% via the SF-12 PCS for fit and frail patients, respectively (P = .0091). In follow-up analyses, 16 of 17 FA tests improved, mostly in younger patients (<70 years old) and responding patients (partial remission or better). CONCLUSIONS Patients may recover from functional and physical limitations under applied MM therapy. The newly established MM-specific FA (via the R-MCI, ADL, MMSE, and SF-12 PCS) allows a precise evaluation of the prognosis and risk status in MM. Its use may improve treatment tolerability and should be validated to individualize MM treatment decisions in the future. LAY SUMMARY The authors performed a prospective functional assessment (FA) in 266 consecutive patients with multiple myeloma at their initial diagnosis. On the basis of univariate and multivariate Cox regression analyses, the authors identified 4 of 17 initially evaluated scores and functional tests as most relevant: the Revised Myeloma Comorbidity Index, Activity of Daily Living, the Mini-Mental State Examination, and the quality-of-life 12-Item Short Form Health Survey Physical Composite Scale. The authors checked the stability of the final model by applying forward and stepwise selection. To evaluate changes in the course of treatment, they reassessed these 17 tests in 165 patients after ≥6 months: 16 of the 17 FA tests improved, mostly in younger patients (<70 years old) and responding patients (partial remission or better).
Collapse
Affiliation(s)
- Sophia Scheubeck
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katja Schoeller
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Holler
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mandy-Deborah Möller
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Heike Reinhardt
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
9
|
Dold SM, Möller MD, Ihorst G, Langer C, Pönisch W, Mügge LO, Knop S, Jung J, Greil C, Wäsch R, Engelhardt M. Validation of the revised myeloma comorbidity index and other comorbidity scores in a multicenter German study group multiple myeloma trial. Haematologica 2021; 106:875-880. [PMID: 32414853 PMCID: PMC7928005 DOI: 10.3324/haematol.2020.254235] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Sandra Maria Dold
- Department of Medicine I Hematology and Oncology, University of Freiburg Medical Center, Faculty of Medicine, Freiburg,Faculty of Biology, University of Freiburg, Freiburg,Comprehensive Cancer Center Freiburg (CCCF), University of Freiburg Medical Center, Faculty of Medicine, Freiburg
| | - Mandy-Deborah Möller
- Department of Medicine I Hematology and Oncology, University of Freiburg Medical Center, Faculty of Medicine, Freiburg,Comprehensive Cancer Center Freiburg (CCCF), University of Freiburg Medical Center, Faculty of Medicine, Freiburg
| | - Gabriele Ihorst
- Clinical Trials Unit, University of Freiburg Medical Center, Freiburg
| | - Christian Langer
- Hematology, Oncology & Rheumatology, University of Ulm Medical Center, Ulm
| | - Wolfram Pönisch
- Hematology & Oncology, University of Leipzig Medical Center, Leipzig
| | - Lars-Olof Mügge
- Hematology & Oncology, University of Jena Medical Center, Jena,Hematology & Oncology, Heinrich-Braun-Klinikum Zwickau, Zwickau
| | - Stefan Knop
- Hematology & Oncology, University of Würzburg Medical Center, Würzburg, Germany
| | - Johannes Jung
- Department of Medicine I Hematology and Oncology, University of Freiburg Medical Center, Faculty of Medicine, Freiburg,Comprehensive Cancer Center Freiburg (CCCF), University of Freiburg Medical Center, Faculty of Medicine, Freiburg
| | - Christine Greil
- Department of Medicine I Hematology and Oncology, University of Freiburg Medical Center, Faculty of Medicine, Freiburg,Comprehensive Cancer Center Freiburg (CCCF), University of Freiburg Medical Center, Faculty of Medicine, Freiburg
| | - Ralph Wäsch
- Department of Medicine I Hematology and Oncology, University of Freiburg Medical Center, Faculty of Medicine, Freiburg,Comprehensive Cancer Center Freiburg (CCCF), University of Freiburg Medical Center, Faculty of Medicine, Freiburg
| | - Monika Engelhardt
- Department of Medicine I Hematology and Oncology, University of Freiburg Medical Center, Faculty of Medicine, Freiburg,Comprehensive Cancer Center Freiburg (CCCF), University of Freiburg Medical Center, Faculty of Medicine, Freiburg
| |
Collapse
|
10
|
Möller MD, Ihorst G, Pahl A, Scheubeck S, Barsch F, Dold SM, Bertz H, Arends J, Wäsch R, Engelhardt M. Physical activity is associated with less comorbidity, better treatment tolerance and improved response in patients with multiple myeloma undergoing stem cell transplantation. J Geriatr Oncol 2020; 12:521-530. [PMID: 33223484 DOI: 10.1016/j.jgo.2020.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/08/2020] [Accepted: 11/13/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Multiple myeloma (MM) is the second most common hematological malignancy. Progression free survival (PFS) and overall survival (OS) have substantially improved, nonetheless MM usually remains incurable. Patients with active disease may be affected by numerous comorbidities, including fatigue, depression and osteolytic lesions, which influence their quality of life (QoL). Albeit, it is known that exercising is beneficial for patients' QoL, few clinical trials are available in patients with MM. We therefore aimed to compare comorbidities and clinical outcome in physically active and inactive patients with MM. MATERIAL AND METHODS We defined physical activity according to WHO criteria (150 min of moderate activity and two sessions of resistance training/week). We matched 53 physically active patients with 53 controls (for age, gender, cytogenetics, disease stage, and therapy) and compared the cohorts for incidence of comorbidities/MM symptoms (osteolytic lesions, anemia, infections, fatigue, depression, Revised-Myeloma Comorbidity Index [R-MCI]) and clinical outcome (treatment tolerance, responses to therapy, PFS and OS) in a retrospective audit. All patients were newly diagnosed with MM and received autologous stem cell transplantations (ASCT) between 2001 and 2017. RESULTS Physically active patients showed superior outcomes in R-MCI (p = 0.0005), fatigue (p = 0.0063), treatment tolerance (p = 0.0258) and hospital stays (p = 0.0072). Furthermore, they showed better treatment responses (p = 0.0366), especially complete remission (CR; p = 0.0018) as well as better OS and PFS. CONCLUSION Physical activity in patients with MM undergoing ASCT seemed associated with better overall clinical outcome. Randomized clinical trials are required to understand the benefits and devise strategies for improving exercising among patients with MM.
Collapse
Affiliation(s)
- Mandy-Deborah Möller
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine, University of Freiburg, Germany
| | - Antonia Pahl
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sophia Scheubeck
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedrich Barsch
- Institute for Movement and Occupational Medicine, Faculty of Medicine, University of Freiburg, Germany
| | - Sandra Maria Dold
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hartmut Bertz
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jann Arends
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| |
Collapse
|
11
|
João C, Geraldes C, Neves M, Mariz M, Trigo F. Management of older and frail patients with multiple myeloma in the Portuguese routine clinical practice: Deliberations and recommendations from an expert panel of hematologists. J Geriatr Oncol 2020; 11:1210-1216. [PMID: 32601004 DOI: 10.1016/j.jgo.2020.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/03/2020] [Accepted: 06/03/2020] [Indexed: 12/20/2022]
Abstract
The management of older patients with Multiple Myeloma (MM) is particularly challenging due to the highly heterogeneous nature of this population, both in terms of physical and cognitive functioning. Older patients may be divided into fit, intermediate and frail, with variable abilities to tolerate treatments. A careful and correct assessment of the frailty status is thus paramount for the success of therapy and for improving outcomes. With the aging of the European population, the number of older patients with MM is rapidly growing. We hereby present the deliberations and recommendations from an expert panel of Portuguese hematologists conducted to discuss the management of this population, including how to stratify and treat older patients with MM according to their frailty status. The use of frailty tools is critical for the development of individualized risk-adapted treatment strategies and to minimize the risk of under or overtreatment. Aggressive therapies should be used in fitter patients to improve survival outcomes, while frail patients should generally be treated with less toxic approaches to control symptoms while minimizing toxicity. In intermediate-fit patients, low-dose triplets are recommended to achieve a balance between improving survival and maintaining quality of life. The management of older patients with MM should be performed by a multidisciplinary team in view of their advanced age and high prevalence of comorbidities. The inclusion of older and frail patients in future clinical trials investigating treatment regimens for MM is crucial to evaluate treatment feasibility and to improve clinical decision making in this population.
Collapse
Affiliation(s)
- Cristina João
- Hemato-Oncology Unit, Champalimaud Centre for the Unknown, Lisboa, Avenida Brasília, 1400-038, Portugal; Nova Medical School, Lisboa, Portugal - Campo Mártires da Pátria 130, 1169-056, Portugal.
| | - Catarina Geraldes
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal - Praceta, Rua Professor Mota Pinto, 3004-561, Portugal.
| | - Manuel Neves
- Hemato-Oncology Unit, Champalimaud Centre for the Unknown, Lisboa, Avenida Brasília, 1400-038, Portugal.
| | - Mário Mariz
- Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal - Rua Dr. António Bernardino de Almeida, 4200-072, Portugal.
| | - Fernanda Trigo
- Centro Hospitalar e Universitário São João do Porto, Porto, Portugal - Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| |
Collapse
|
12
|
Defining the vulnerable patient with myeloma-a frailty position paper of the European Myeloma Network. Leukemia 2020; 34:2285-2294. [PMID: 32555295 DOI: 10.1038/s41375-020-0918-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 12/20/2022]
Abstract
As the treatment landscape continues to evolve towards the application of precision medicine in multiple myeloma (MM), there is a clear need to identify those patients who are at risk of not achieving the maximum benefit whilst exposed to the highest level of toxicity. This group of patients, defined as frail, is an unmet clinical need. However, how we define such a vulnerable group of patients with MM remains to be clarified. An integral aspect of this is to define the physiological age and capacity of patients with MM to deal with the burden of their disease and it's treatment. Such assessments may include not only functional and clinical assessments but also laboratory-based biomarkers of frailty, aging and senescent cellular burden. A need to develop, test and validate clinical screening scores before their adoption into clinical practice is mandated. This position paper from the European Myeloma Network aims to review what is known about defining frailty in MM, and how we can advance this knowledge for the design of clinical trials and ultimately how we deliver treatment in the clinic.
Collapse
|
13
|
Schinke M, Ihorst G, Duyster J, Wäsch R, Schumacher M, Engelhardt M. Risk of disease recurrence and survival in patients with multiple myeloma: A German Study Group analysis using a conditional survival approach with long-term follow-up of 815 patients. Cancer 2020; 126:3504-3515. [PMID: 32459378 DOI: 10.1002/cncr.32978] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Unlike the traditional method of overall survival prediction in patients with cancer, conditional survival predicts the survival of patients dynamically throughout the course of disease, identifying how a prognosis evolves over time. METHODS The authors assessed 815 consecutive patients with multiple myeloma through the German Study Group on Multiple Myeloma (Deutsche Studiengruppe Multiples Myelom; DSMM) incentive. Over 10 variables, including patient-specific and multiple myeloma-specific parameters, were analyzed at the time of initial diagnosis and repeatedly during follow-up. The probability of survival for another 5 years was calculated according to disease-related and host-related risks. Multivariate Cox models were used to determine baseline and updated prognostic factors for survival. RESULTS The median follow-up and overall survival were 10.3 years and 5.1 years, respectively. When comparing 5-year conditional survival probabilities from the data derived at the time of initial diagnosis with those updated over time, substantially differing prognoses were observed when follow-up data were used. Multivariate Cox regression models for cohorts surviving 0 to 5 years demonstrated hazard ratios (HRs) for patients aged <60 years, 60 to 69 years, and >70 years of 1, 1.68, and 3.17, respectively. These HRs for age were found to decline for patients surviving 5 years, as well as for those with advanced stages of disease (II/III) and unfavorable cytogenetics, whereas progressive disease remained an important factor in patients surviving 1 year, 3 years, and 5 years, with HRs of 1.85, 2.11, and 2.14, respectively. CONCLUSIONS To the authors' knowledge, the current study is the first analysis of conditional survival in patients with multiple myeloma using both baseline and follow-up risk parameters, demonstrating that regular risk assessment throughout the course of disease and complete follow-up provide a more reliable conditional survival estimation than baseline assessment alone.
Collapse
Affiliation(s)
- Maximilian Schinke
- Department of Medicine I, University of Freiburg Medical Center, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, University of Freiburg Medical Center, Freiburg, Germany
| | - Justus Duyster
- Department of Medicine I, University of Freiburg Medical Center, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I, University of Freiburg Medical Center, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Schumacher
- Center for Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I, University of Freiburg Medical Center, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
14
|
Engelhardt M, Ihorst G, Duque-Afonso J, Wedding U, Spät-Schwalbe E, Goede V, Kolb G, Stauder R, Wäsch R. Structured assessment of frailty in multiple myeloma as a paradigm of individualized treatment algorithms in cancer patients at advanced age. Haematologica 2020; 105:1183-1188. [PMID: 32241848 PMCID: PMC7193478 DOI: 10.3324/haematol.2019.242958] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/30/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Monika Engelhardt
- Department of Medicine I, Hematology, Oncology and Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Jesus Duque-Afonso
- Department of Medicine I, Hematology, Oncology and Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Ernst Spät-Schwalbe
- Vivantes Klinikum Spandau, Innere Medizin, Hämatologie, Onkologie, Palliativmedizin, Berlin, Germany
| | | | - Gerald Kolb
- Bonifatius Hospital Lingen, Medizinische Klinik, Fachbereich Geriatrie, Akademisches Lehrkrankenhaus der Westfälischen Wilhelms-Universität Münster, Münster, Germany
| | - Reinhard Stauder
- Universitätsklinik für Innere Medizin V (Hämatologie und Onkologie), Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Ralph Wäsch
- Department of Medicine I, Hematology, Oncology and Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
15
|
Graziani G, Herget GW, Ihorst G, Zeissig M, Chaidos A, Auner HW, Duyster J, Wäsch R, Engelhardt M. Time from first symptom onset to the final diagnosis of multiple myeloma (MM) - possible risks and future solutions: retrospective and prospective 'Deutsche Studiengruppe MM' (DSMM) and 'European Myeloma Network' (EMN) analysis .. Leuk Lymphoma 2020; 61:875-886. [PMID: 31779510 DOI: 10.1080/10428194.2019.1695051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/30/2019] [Accepted: 11/06/2019] [Indexed: 01/10/2023]
Abstract
Multiple myeloma (MM) often presents with unspecific symptoms and is challenging to diagnose. We performed this DSMM/EMN-analysis via test-(retro-) and validation (prospective) study to determine the time interval from the onset of first symptoms to the diagnosis of MM. The retrospective and prospective analyses were performed in 101 and 176 patients, respectively. The median time from first symptoms to the MM diagnosis in both cohorts was 4 and 6 months, respectively. Frequencies of MM-related pathologic bone fractures, renal, and infectious complications at diagnosis occurred in 41%, 35%, and 16% of patients, respectively. Our MM-questionnaire determined that 39% of patients were dissatisfied with the diagnostic process. PFS and OS proved insignificantly different with shorter (≤6) and longer (>6 months) latency periods. In conclusion, our in depth studies demonstrate that delays in diagnosis do not decrease PFS or OS, but induce MM-related complications and influence patients' satisfaction with their medical care.
Collapse
Affiliation(s)
- Giulia Graziani
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georg W Herget
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mara Zeissig
- Myeloma Research Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Holger W Auner
- Centre for Hematology, Imperial College London, London, UK
| | - Justus Duyster
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
16
|
Kovacs SB, Luan J, Dold SM, Weis A, Pantic M, Duyster J, Wäsch R, Engelhardt M. Venetoclax in combination with carfilzomib, doxorubicin and dexamethasone restores responsiveness in an otherwise treatment-refractory multiple myeloma patient. Haematologica 2020; 105:e138-e140. [PMID: 31467125 PMCID: PMC7049367 DOI: 10.3324/haematol.2019.232330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sarolta Bojtine Kovacs
- Departments of Medicine 1, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg
| | - Jingting Luan
- Departments of Medicine 1, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg
| | - Sandra Maria Dold
- Departments of Medicine 1, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg
- Faculty of Biology, University of Freiburg
| | - Andreas Weis
- Departments of Medicine 1, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Milena Pantic
- Departments of Medicine 1, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg
| | - Justus Duyster
- Departments of Medicine 1, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Departments of Medicine 1, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Departments of Medicine 1, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|