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Tanabe K, Tanabe J. Role of echocardiography in patients treated with immune checkpoints inhibitors. J Echocardiogr 2023; 21:145-148. [PMID: 37644319 DOI: 10.1007/s12574-023-00621-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Abstract
Immune-related adverse events occurring in the heart (cardiac immune-related adverse events; irAEs) by immune checkpoint inhibitors (ICIs) include myocarditis, arrhythmia, conduction disturbance, pericardial diseases, and takotsubo cardiomyopathy. Cardiac irAEs are rare but life-threatening. In cardio-oncology, the study of cardiac disorders caused by cancer treatment has recently attracted attention, and such studies may elucidate the pathophysiology of cardiac irAEs and contribute to management strategies. This review discusses the pathogenic mechanisms underlying cardiac irAEs and the role of echocardiography in patients treated with ICIs.
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Affiliation(s)
- Kazuaki Tanabe
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Japan.
| | - Junya Tanabe
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Japan
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2
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Minegishi S, Kinguchi S, Horita N, Namkoong H, Briasoulis A, Ishigami T, Tamura K, Nishiyama A, Yano Y. Immune Checkpoint Inhibitors Do Not Increase Short-Term Risk of Hypertension in Cancer Patients: a Systematic Literature Review and Meta-Analysis. Hypertension 2022; 79:2611-2621. [DOI: 10.1161/hypertensionaha.122.19865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Immune checkpoint inhibitors (ICIs) are becoming widely used for novel cancer treatments. Immune-related adverse events, including cardiac toxicity, are frequently observed following immune checkpoint inhibitor (ICI) use. However, little is known regarding the association between ICIs initiation and hypertension in cancer patients.
Methods:
A systematic literature search was performed using PubMed, EMBASE, Cochrane Library, and Web of Science Core Collection. The risk of hypertension associated with ICI initiation in randomized controlled trials (RCTs) was evaluated. Hypertension was categorized according to the Common Terminology Criteria for Adverse Events. The odds ratios of grades I to V and grades III to V hypertension were calculated using a random-effects meta-analysis.
Results:
Thirty-two RCTs (n=19 810 cancer patients) were included. At a median follow-up of 36 months, the median overall survival was 15 months in the ICI group. ICI initiation was not significantly associated with hypertension (grades I–V: odds ratio, 1.12 [95% CI, 0.96–1.30]; grades III–V: odds ratio, 0.95 [95% CI, 0.78–1.16]). Additionally, no significant differences in hypertension risk were evident in ICI combination therapies with various drugs, including anti-VEGF (vascular endothelial growth factor) agents. In a subgroup analysis based on clinical setting (placebo RCT versus nonplacebo RCT), there were discrepancies between the results obtained with different methodologies, with patients in the nonplacebo RCTs having higher grades I–V hypertension (I
2
=88.6%,
P
for heterogeneity=0.003).
Conclusions:
ICI initiation was not associated with short-term risk of hypertension in cancer patients, and the association was similar regardless of concomitant treatment with other anticancer drugs.
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Affiliation(s)
- Shintaro Minegishi
- Department of Medical Science and Cardio-Renal Medicine, Yokohama City University Graduate School of Medicine, Japan (S.M., S.K., T.I., K.T.)
| | - Sho Kinguchi
- Department of Medical Science and Cardio-Renal Medicine, Yokohama City University Graduate School of Medicine, Japan (S.M., S.K., T.I., K.T.)
| | - Nobuyuki Horita
- Chemotherapy Center, Yokohama City University Hospital, Japan (N.H.)
| | - Ho Namkoong
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan (H.N.)
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa College of Medicine, Iowa City (A.B.)
| | - Tomoaki Ishigami
- Department of Medical Science and Cardio-Renal Medicine, Yokohama City University Graduate School of Medicine, Japan (S.M., S.K., T.I., K.T.)
| | - Kouichi Tamura
- Department of Medical Science and Cardio-Renal Medicine, Yokohama City University Graduate School of Medicine, Japan (S.M., S.K., T.I., K.T.)
| | - Akira Nishiyama
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Japan (A.N.)
| | - Yuichiro Yano
- NCD Epidemiology Research Center (NERC), Shiga University of Medical Science, Otsu, Japan (Y.Y.)
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3
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Takada S, Kinugawa S, Handa H, Yokota T, Sabe H. Cross-disease communication between cancer and heart failure provides a rational approach to prevention and treatment of both diseases. Front Oncol 2022; 12:1006322. [PMID: 36387253 PMCID: PMC9661194 DOI: 10.3389/fonc.2022.1006322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/29/2022] [Indexed: 11/21/2022] Open
Abstract
Accumulating clinical data have demonstrated a clear positive association between cancer and cardiac disorders, particularly chronic heart failure (CHF). These two diseases can be mutual drivers of each other, and hence frequently co-occur in patients. The immune system is the core mechanism that eliminates transformed cells from our bodies. However, immune cells often play distinct or even conflicting roles in cancer and CHF. Moreover, CHF alters the properties of immune cells, particularly those of regulatory T cells. Our previous study showed that the oxidative phosphorylation capacity of peripheral blood mononuclear cells is impaired in CHF, leading to the increased production of reactive oxygen species. Therefore, the co-occurrence of cancer and CHF becomes a serious problem, affecting the treatment of both diseases, and consequently negatively affecting patient survival rates. To date, few methods have been identified that effectively treat both diseases at the same time. Mitochondria activity may change in immune cells during their activation and exhaustion, and in CHF. Mitochondria activity is also largely affected in myocardia in CHF. We here focus on the mitochondrial abnormalities of immune cells in cancer and CHF, and discuss possible ways to treat cancer and CHF at the same time by targeting mitochondrial abnormalities. Many cancer cells are inevitably produced daily in our bodies, mostly owing to enzymatic nucleotide errors of DNA replication and repair. Therefore, the possibility of ways to prevent cancer by preventing the onset of heart failure will also be discussed.
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Affiliation(s)
- Shingo Takada
- Department of Lifelong Sport, School of Sports Education, Hokusho University, Ebetsu, Japan
- Department of Molecular Biology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- *Correspondence: Shingo Takada, ;
; Shintaro Kinugawa, ; Hisataka Sabe, ;
| | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- *Correspondence: Shingo Takada, ;
; Shintaro Kinugawa, ; Hisataka Sabe, ;
| | - Haruka Handa
- Department of Molecular Biology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takashi Yokota
- Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Hisataka Sabe
- Department of Molecular Biology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Institute for Genetic Medicine, Hokkaido University, Sapporo, Japan
- *Correspondence: Shingo Takada, ;
; Shintaro Kinugawa, ; Hisataka Sabe, ;
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4
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Longinow J, Zmaili M, Skoza W, Kondoleon N, Marquardt R, Calabrese C, Funchain P, Moudgil R. Immune checkpoint inhibitor induced myocarditis, myasthenia gravis, and myositis: A single-center case series. Cancer Med 2022; 12:2281-2289. [PMID: 36128926 PMCID: PMC9939107 DOI: 10.1002/cam4.5050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/07/2022] [Accepted: 06/15/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors can result in overlap syndrome comprised of myasthenia gravis, myositis and myocarditis. However, the mortality predictors have not been clearly delineated. METHODS We examined the characteristics of 11 patients diagnosed with overlap syndrome at Cleveland Clinic. All the available clinical, diagnostic, biochemical and disease specific factors were examined. Clinical predictors of increased mortality were using student t-test for parametric data and Wilcoxon-signed rank testing for nonparametric data. RESULTS Seven patients out of eleven patients were alive during the analysis. Our study did confirm that troponins were indicator of early demise. However, study showed that elevated creatinine, BUN, and decreased hemoglobin were also observed in patients who met early demise. Unlike previously published studies, elevated NT Pro-BNP and reduced left ventricular ejection fraction were not a seen in this study. However, there were higher incidence of electrical abnormalities in deceased patients when compared to alive. CONCLUSION Our study is first to examine various clinical parameters of overlap syndrome that might be predictive of mortality. This study confirms troponin as possible predictor and adds elevated creatinine, BUN and reduced hemoglobin as possible early biomarkers in deceased patients. The analysis showed that reduced LVEF was not a seen in deceased patients.
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Affiliation(s)
- Joshua Longinow
- Department of Internal MedicineCleveland Clinic FoundationClevelandOhioUSA
| | - Mohammad Zmaili
- Section of Clinical Cardiology, Department of Cardiovascular Medicine, Heart and Vascular InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Warren Skoza
- Department of Internal MedicineCleveland Clinic FoundationClevelandOhioUSA
| | - Nicholas Kondoleon
- Department of Internal MedicineCleveland Clinic FoundationClevelandOhioUSA
| | - Robert Marquardt
- Department of Internal MedicineCleveland Clinic FoundationClevelandOhioUSA,Division of Neuromuscular CenterCleveland Clinic FoundationClevelandOhioUSA
| | - Cassandra Calabrese
- Department of Internal MedicineCleveland Clinic FoundationClevelandOhioUSA,Section of Rheumatologic and Immunologic DiseaseCleveland Clinic FoundationClevelandOhioUSA
| | - Pauline Funchain
- Department of Internal MedicineCleveland Clinic FoundationClevelandOhioUSA,Taussig Cancer Institute and Case Comprehensive Cancer CenterCleveland Clinic FoundationClevelandOhioUSA
| | - Rohit Moudgil
- Department of Internal MedicineCleveland Clinic FoundationClevelandOhioUSA,Section of Clinical Cardiology, Department of Cardiovascular Medicine, Heart and Vascular InstituteCleveland Clinic FoundationClevelandOhioUSA
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5
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Kadowaki H, Akazawa H. Sick Sinus Syndrome: More Than a Needle-in-a-haystack Manifestation of Immune Checkpoint Inhibitor-associated Myocarditis. Intern Med 2022; 61:2101-2102. [PMID: 35283389 PMCID: PMC9381345 DOI: 10.2169/internalmedicine.9033-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Hiroshi Kadowaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hiroshi Akazawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Japan
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6
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Shindo A, Yamasaki M, Uchino K, Yamasaki M. Asymptomatic Myocarditis with Mild Cardiac Marker Elevation Following Nivolumab-Induced Myositis. Int Heart J 2022; 63:180-183. [DOI: 10.1536/ihj.21-653] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Akito Shindo
- Department of Cardiology, NTT Medical Center Tokyo
| | | | - Keita Uchino
- Department of Medical Oncology, NTT Medical Center Tokyo
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7
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Kadowaki H, Ishida J, Uehara M, Ishizuka M, Kiyosue A, Hatano M, Shimada S, Ono M, Akazawa H, Komuro I. Detection of Profound Myocardial Damage by Cardiac MRI in a Patient with Severe Cardiotoxicity Induced by Anti-HER2 Therapy. Int Heart J 2021; 62:1436-1441. [PMID: 34853231 DOI: 10.1536/ihj.21-388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Anti-HER2 therapy has greatly improved the long-term prognosis of patients with HER2-positive breast cancer. Meanwhile, by interfering with the protective effects of neuregulin-1/HER2 signaling on stressed cardiomyocytes, anti-HER2 therapy occasionally induces reversible cancer therapeutics-related cardiac dysfunction (CTRCD). Cardiac magnetic resonance (CMR) parametric mapping or myocardial feature-tracking, in combination with late gadolinium enhancement (LGE) imaging, has the potential to detect changes in the myocardium in anti-HER2 therapy-related cardiac dysfunction. Here we report a breast cancer patient who experienced life-threatening CTRCD after treatment with trastuzumab plus pertuzumab. This case showed multiple transmural LGE-positive myocardial lesions in CMR imaging and high native T1 and T2 values in CMR parametric mapping, which was apparently more extensive than those observed in most patients with anti-HER2 therapy-related cardiac dysfunction. Consistent with profound myocardial damage indicated by CMR, her cardiac function was not fully restored despite intensive care and cardioprotective drug therapy. These findings suggest the potential usefulness of LGE imaging and parametric mapping by CMR for the assessment of myocardial injury to determine the clinical severity of anti-HER2 therapy-related cardiac dysfunction.
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Affiliation(s)
| | - Junichi Ishida
- Department of Cardiovascular Medicine, The University of Tokyo
| | - Masae Uehara
- Department of Cardiovascular Medicine, The University of Tokyo
| | - Masato Ishizuka
- Department of Cardiovascular Medicine, The University of Tokyo
| | - Arihiro Kiyosue
- Department of Cardiovascular Medicine, The University of Tokyo
| | - Masaru Hatano
- Department of Cardiovascular Medicine, The University of Tokyo
| | - Shogo Shimada
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Hiroshi Akazawa
- Department of Cardiovascular Medicine, The University of Tokyo
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo
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8
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Matsumoto T, Fukuda K, Yoshida T, Shimazu K, Taguchi D, Shinozaki H, Seki K, Yamanaka T, Ootaka M, Nanjyo H, Watanabe H, Shibata H. Sudden and severe cardiotoxicity induced with pembrolizumab, its clinical course, therapeutic intervention, and outcome. Int Cancer Conf J 2021; 11:81-86. [DOI: 10.1007/s13691-021-00525-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/12/2021] [Indexed: 12/26/2022] Open
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9
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Thakker RA, Lee MA, Albaeni A, Elbadawi A, Suthar KH, Perez C, Sonstein LK, Farr NM, Venkatesan R, Khalife W, Berbarie RF, Chatila KF. Clinical Characteristics and Outcomes in Immune Checkpoint Inhibitor Therapy-Associated Myocarditis. Cardiol Res 2021; 12:270-278. [PMID: 34691324 PMCID: PMC8510657 DOI: 10.14740/cr1319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) therapy has played an important role in the treatment of several groups of cancers. Although a life prolonging treatment, many side effects have been shown with ICI therapy. This study looked at individual level clinical characteristics and outcomes with ICI therapy in patients who developed ICI-related myocarditis. A comprehensive review of the National Library of Medicine PubMed database was performed. Inclusion criteria were all studies that were composed of case reports and case series of individual patients undergoing ICI therapy that developed myocarditis. To appreciate individual patient level data, observational studies, clinical trials, systematic reviews, and meta-analyses were excluded. Our search yielded 333 results with 71 cases reviewed of ICI therapy-related myocarditis. The findings included an average age of 68 years, higher incidence in men, and pretreatment cardiac history of hypertension. Melanoma was the most prevalent malignancy with nivolumab being the most used ICI therapy. Heart failure was the most prevalent adverse event that was co-prevalent with myocarditis. Corticosteroid therapy alone was the most utilized therapy to treat ICI-related myocarditis. Mortality was seen in nearly half of the patient population. Our study reviewed the preexisting literature of prior reported myocarditis secondary to ICI therapy. Periodic surveillance should be performed by the cardio-oncologist and internist. Due to the expanding role of ICI therapy in treating a variety of cancer patients, appreciation of its impact on the development of myocarditis is needed.
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Affiliation(s)
- Ravi A Thakker
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Marissa A Lee
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Aiham Albaeni
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Ayman Elbadawi
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Krishna H Suthar
- Department of Hematology and Medical Oncology, Baylor Scott and White Medical Center, Temple, TX, USA
| | - Christopher Perez
- Cardiovascular Institute, Baylor Scott and White Medical Center, Temple, TX, USA
| | - Lindsay K Sonstein
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Norman M Farr
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Rohit Venkatesan
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Galveston, TX, USA
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Rafic F Berbarie
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Khaled F Chatila
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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Mocan-Hognogi DL, Trancǎ S, Farcaş AD, Mocan-Hognogi RF, Pârvu AV, Bojan AS. Immune Checkpoint Inhibitors and the Heart. Front Cardiovasc Med 2021; 8:726426. [PMID: 34660728 PMCID: PMC8511816 DOI: 10.3389/fcvm.2021.726426] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/23/2021] [Indexed: 12/15/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) represent a break-through treatment for a large number of cancer types. This treatment is increasingly being recommended. ICIs are prescribed for primary tumours and for metastases, adjuvant/neo-adjuvant therapy. Thus, there is an increased need for expertise in the field, including the ways of response and toxicities related to them. ICIs become toxic because of the removal of self-tolerance, which in turn induces autoimmune processes that affect every organ. However, when relating to the heart, it has been noticed to be leading to acute heart failure and even death caused by various mechanisms, such as: myocarditis, pericarditis, arrhythmia, and Takotsubo cardiomyopathy. This review aims to address the above issues by focusing on the latest findings on the topic, by adding some insights on the mechanism of action of ICIs with a special focus on the myocardial tissue, by providing information on clinical manifestations, diagnosis and (wherever possible) treatment of the cardiotoxic events related to this therapy. The information is expanding and in many cases, the articles we found refer mainly to case-presentations and studies conducted on small populations. However, we consider that it is worthwhile to raise awareness of this new treatment, especially since it is widely now and it provides a significant increase in the survival rate in patients who receive it.
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Affiliation(s)
- Diana Larisa Mocan-Hognogi
- Internal Medicine Department, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1st Cardiology Department, Emergency Clinical County Hospital, Cluj-Napoca, Romania
| | - Sebastian Trancǎ
- Surgery Department, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Intensive Care Department, Emergency Clinical County Hospital, Cluj-Napoca, Romania
| | - Anca Daniela Farcaş
- Internal Medicine Department, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1st Cardiology Department, Emergency Clinical County Hospital, Cluj-Napoca, Romania
| | - Radu Florin Mocan-Hognogi
- Mother and Child Department, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,2nd Gynecology Department, Emergency Clinical County Hospital, Cluj-Napoca, Romania
| | - Andrada Viorica Pârvu
- Oncology Department, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Hematological Department, "Prof. Dr. Ioan Chiricuţǎ" Oncology Institute, Cluj-Napoca, Romania
| | - Anca Simona Bojan
- Oncology Department, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Hematological Department, "Prof. Dr. Ioan Chiricuţǎ" Oncology Institute, Cluj-Napoca, Romania
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