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Gouda MA, Janku F, Wahida A, Buschhorn L, Schneeweiss A, Abdel Karim N, De Miguel Perez D, Del Re M, Russo A, Curigliano G, Rolfo C, Subbiah V. Liquid Biopsy Response Evaluation Criteria in Solid Tumors (LB-RECIST). Ann Oncol 2024; 35:267-275. [PMID: 38145866 DOI: 10.1016/j.annonc.2023.12.007] [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: 06/28/2023] [Revised: 10/17/2023] [Accepted: 12/09/2023] [Indexed: 12/27/2023] Open
Abstract
Current evaluation of treatment response in solid tumors depends on dynamic changes in tumor diameters as measured by imaging. However, these changes can only be detected when there are enough macroscopic changes in tumor volume, which limits the usability of radiological response criteria in evaluating earlier stages of disease response and necessitates much time to lapse for gross changes to be notable. One promising approach is to incorporate dynamic changes in circulating tumor DNA (ctDNA), which occur early in the course of therapy and can predict tumor responses weeks before gross size changes manifest. However, several issues need to be addressed before recommending the implementation of ctDNA response criteria in daily clinical practice such as clinical, biological, and regulatory challenges and, most importantly, the need to standardize/harmonize detection methods and ways to define ctDNA response and/or progression for precision oncology. Herein, we review the use of liquid biopsy (LB) to evaluate response in solid tumors and propose a plan toward standardization of LB-RECIST.
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Affiliation(s)
- M A Gouda
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston
| | - F Janku
- Monte Rosa Therapeutics, Boston, USA
| | - A Wahida
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - L Buschhorn
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - A Schneeweiss
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - N Abdel Karim
- Inova Schar Cancer Institute, Fairfax, (5)University of Virginia, Charlottesville
| | - D De Miguel Perez
- Center for Thoracic Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - M Del Re
- Center for Thoracic Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - A Russo
- Medical Oncology Unit, Papardo Civil Hospital and Department of Human Pathology, University of Messina, Messina
| | - G Curigliano
- Department of Oncology and Hemato-Oncology, University of Milano, Milano; Division of Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milano, Italy
| | - C Rolfo
- Center for Thoracic Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - V Subbiah
- Sarah Cannon Research Institute, Nashville, USA.
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2
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Pixberg C, Schulze M, Buschhorn L, Suppelna JP, Mock A, Hlevnjak M, Heublein S, Schumacher-Wulf E, Schneeweiss A. Reimbursement in the Context of Precision Oncology Approaches in Metastatic Breast Cancer: Challenges and Experiences. Breast Care (Basel) 2024; 19:10-17. [PMID: 38384493 PMCID: PMC10878710 DOI: 10.1159/000533902] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/30/2023] [Indexed: 02/23/2024] Open
Abstract
Background Precision oncology programs using next-generation sequencing to detect predictive biomarkers are extending therapeutic options for patients with metastatic breast cancer (mBC). Regularly, based on the recommendations of the interdisciplinary molecular tumor board (iMTB), an inclusion in a clinical trial is not possible. In this case, the German health insurance system allows for the application of reimbursement for an off-label drug use. Here, we describe the current challenges and our experience with reimbursement of molecular therapies in mBC. Methods A total of 100 applications for reimbursement of off-label therapies recommended by an iMTB were filed for patients with mBC, of which 89 were evaluable for this analysis. The approval rate was correlated with the molecular level of evidence of the respective therapy according to the National Center for Tumor Diseases (NCT) and European Society for Medical Oncology Scale for Clinical Actionability of molecular Targets (ESCAT) classification as well as with pretreatment therapy lines. Findings Overall, 53.9% (48/89) of reimbursement applications were approved. Applications for therapies based on level of evidence m1 (NCT classification), tier I and II (ESCAT classification) had a significantly and clinically relevant increased chance of reimbursement, while a greater number of previous treatment lines had no significantly increased chance of approval, though a trend of approval toward higher treatment lines was detectable. Interpretation Currently, the German jurisdiction seems to aggravate the clinical implementation of clinically urgently needed molecular therapies.
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Affiliation(s)
- Constantin Pixberg
- Molecular Diagnostics Program, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Markus Schulze
- Molecular Diagnostics Program, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
- Division of Molecular Genetics, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lars Buschhorn
- Molecular Diagnostics Program, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Molecular Genetics, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jan Philip Suppelna
- Molecular Diagnostics Program, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Molecular Genetics, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andreas Mock
- Department of Medical Oncology, National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
- Department of Translational Medical Oncology, NCT Heidelberg, DKFZ, Heidelberg, Germany
| | - Mario Hlevnjak
- Molecular Diagnostics Program, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
- Division of Molecular Genetics, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sabine Heublein
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Obstetrics and Gynecology, Medical School, University of Heidelberg, Heidelberg, Germany
| | | | - Andreas Schneeweiss
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), University of Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Buschhorn L, Odoni DI, Geuder J, Odinius TO, Wagner CV, Jilg S, Höckendorf U, Wahida A, Schlesner M, Reiter A, Jawhar M, Jost PJ. Transcriptomic profiling does not refine mastocytosis diagnosis. Haematologica 2023; 108:3125-3130. [PMID: 37165843 PMCID: PMC10620558 DOI: 10.3324/haematol.2022.282617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/04/2023] [Indexed: 05/12/2023] Open
Affiliation(s)
- Lars Buschhorn
- Division of Molecular Genetics, German Cancer Research Center (DKFZ), Heidelberg, Germany; Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany; Department of Internal Medicine III, School of Medicine, Technical University of Munich, Munich
| | - Dorett I Odoni
- Bioinformatics and Omics Data Analytics, German Cancer Research Center, Heidelberg, Germany; Biomedical Informatics, Data Mining and Data Analytics, Augsburg University, Augsburg
| | - Johanna Geuder
- Anthropology and Human Genomics, Faculty of Biology, Ludwig-Maximilians University, Martinsried
| | - Timo O Odinius
- Department of Internal Medicine III, School of Medicine, Technical University of Munich, Munich
| | - Celina V Wagner
- Department of Internal Medicine III, School of Medicine, Technical University of Munich, Munich
| | - Stefanie Jilg
- Department of Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany; Onkologie Erding, Erding
| | - Ulrike Höckendorf
- Department of Internal Medicine III, School of Medicine, Technical University of Munich, Munich
| | - Adam Wahida
- Division of Molecular Genetics, German Cancer Research Center (DKFZ), Heidelberg, Germany; Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany; Department of Internal Medicine III, School of Medicine, Technical University of Munich, Munich
| | - Matthias Schlesner
- Bioinformatics and Omics Data Analytics, German Cancer Research Center, Heidelberg, Germany; Biomedical Informatics, Data Mining and Data Analytics, Augsburg University, Augsburg
| | - Andreas Reiter
- Medical Department III for Hematology and Oncology, University Clinic Mannheim, Mannheim
| | - Mohamad Jawhar
- Medical Department III for Hematology and Oncology, University Clinic Mannheim, Mannheim
| | - Philipp J Jost
- Department of Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany; Division of Clinical Oncology, Department of Internal Medicine, Medical University of Graz, Graz.
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Kairemo K, Gouda MA, Buschhorn L, Wahida A, Macapinlac HA, Anderson PM, Subbiah V. Sodium fluoride (Na 18F) PET Response Criteria in Solid Tumors (NAFCIST): a framework for response assessment in bone tumors. ESMO Open 2023; 8:101575. [PMID: 37517365 PMCID: PMC10400850 DOI: 10.1016/j.esmoop.2023.101575] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 08/01/2023] Open
Abstract
The current Response Evaluation Criteria in Solid Tumors for measuring tumor response in osteosarcoma may be sub-optimal, as even responsive bone tumors may show limited change in tumor diameters. This limits the use of traditional imaging assessment tools. Therefore, discerning osteosarcoma response to therapy on magnetic resonance imaging before surgery is often difficult, and it is typically evaluated after surgery by assessing the amount of necrosis in resected surgical specimens. To address these challenges, sodium fluoride (Na18F) positron emission tomography/computed tomography (PET/CT) scans can be utilized to better image bone response to therapy, as, fluoride is avidly taken up by bone. Na18F Response Criteria in Solid Tumors (NAFCIST) has been developed as a novel method to evaluate treatment response using Na18F PET/CT. Current evidence supporting NAFCIST comes from a pilot study that evaluated alpha particle radium-223 in patients with osteosarcoma. In this review, practical guidance for utilizing NAFCIST in the context of bone tumors is illustrated to aid future studies.
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Affiliation(s)
- K Kairemo
- Department of Nuclear Medicine, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston
| | - M A Gouda
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - L Buschhorn
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - A Wahida
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - H A Macapinlac
- Department of Nuclear Medicine, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston
| | - P M Anderson
- Department of Hematology/Oncology and Bone marrow Transplant, Cleveland Clinic Children's, Cleveland, USA
| | - V Subbiah
- Sarah Cannon Research Institute, Nashville, USA.
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Gouda MA, Buschhorn L, Schneeweiss A, Wahida A, Subbiah V. N-of-1 Trials in Cancer Drug Development. Cancer Discov 2023:OF1-OF9. [PMID: 37070849 DOI: 10.1158/2159-8290.cd-22-1377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 01/23/2023] [Accepted: 02/24/2023] [Indexed: 04/19/2023]
Abstract
SUMMARY The current approaches for cancer drug development lag behind an accelerated need in the field for a fast and efficient method for evaluating drugs in the personalized medicine era. In that regard, N-of-1 studies emerge as a potential addition to the drug development arsenal, although there are several considerations before its broad application becomes feasible. In essence, N-of-1 trials are a departure from the traditional "drug-centric" model to a "patient-centric" model. Herein, we review the concept of N-of-1 trials and provide real-world examples of their use in the developmental therapeutics field. N-of-1 trials offer an exceptional opportunity for fast-tracking of cancer drug development in the precision oncology era.
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Affiliation(s)
- Mohamed A Gouda
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lars Buschhorn
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Andreas Schneeweiss
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Adam Wahida
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Vivek Subbiah
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
- MD Anderson Cancer Network, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Gouda MA, Nelson BE, Buschhorn L, Wahida A, Subbiah V. Tumor-Agnostic Precision Medicine from the AACR GENIE Database: Clinical implications. Clin Cancer Res 2023:725160. [PMID: 37061987 PMCID: PMC10390861 DOI: 10.1158/1078-0432.ccr-23-0090] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/15/2023] [Accepted: 03/15/2023] [Indexed: 04/17/2023]
Abstract
Biomarker-driven cancer therapy has revolutionized precision oncology. With a better understanding of tumor biology, tissue-agnostic targets have been characterized and explored which ultimately led to therapeutics with pan-cancer efficacy. To date, five molecular biomarkers have obtained FDA tissue-agnostic approval for targeted therapies and immunotherapies. Those include BRAF V600E mutations, RET fusions, NTRK fusions, high tumor mutation burden (TMB), and deficient mismatch repair (dMMR/MSI-High). Herein, we have used data from AACR project GENIE to explore the clinico-genomic landscape of these alterations. AACR GENIE is a publicly accessible registry of genomic data from multiple collaborating cancer centers. Current database (version 13.0) includes sequencing data of 168,423 samples collected from patients with different cancers. We were able to identify BRAF V600E, RET fusions, NTRK fusions, and high TMB in 2.9%, 1.6%, 1.5%, and 15.2% of pan-cancer samples; respectively. In this article, we describe the distribution of those tissue-agnostic targets among different cancer types. In addition, we summarize the current prospect on the biology of these alterations and evidence on approved drugs including pembrolizumab, dostarilmab, larotrectinib, entrectinib, selpercatinib, and dabrafenib/trametinib combination.
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Affiliation(s)
- Mohamed A Gouda
- The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | | | | | - Adam Wahida
- National Center for Tumor Diseases, Heidelberg, Germany
| | - Vivek Subbiah
- The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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7
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Schneeweiss A, Buschhorn L. [Breast-like cancer of unknow primary : Implications for radiological diagnostics]. Radiologie (Heidelb) 2023; 63:366-370. [PMID: 36976360 DOI: 10.1007/s00117-023-01136-5] [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] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Cancer of unknown primary (CUP) is defined by the presence of metastatic disease with an undetectable primary tumor at the time of presentation despite standard-of-care imaging. Although the prognosis of most CUP patients is poor, certain subgroups with more favorable prognosis have been defined. DIAGNOSTICS Women with isolated axillary lymph node metastases and confirmed histologic adenocarcinoma or poorly differentiated subtype, no other distant metastases, and no evidence of a primary cancer including primary breast carcinoma evaluated by clinical examination, computed tomography of thorax and abdomen, mammography, breast ultrasound, and breast magnetic resonance imaging (MRI) represent a potentially curable subgroup of patients with CUP. Breast MRI is the most important radiological modality in the diagnostic workup of breast-like CUP to exclude a primary cancer in the breast. THERAPY Breast-like CUP patients are treated according to guidelines for patients with node-positive breast cancer. Standard-of-care adjuvant systemic therapy should be given. Axillary lymph node dissection (ALND) is indicated. If no primary cancer in the breast is detected, surgery of the ipsilateral breast should not be performed. Radiotherapy of the ipsilateral breast and supra-/infraclavicular lymph nodes should be discussed.
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Affiliation(s)
- Andreas Schneeweiss
- Sektion für Gynäkologische Onkologie, Nationales Centrum für Tumorerkrankungen (NCT), Heidelberg, Deutschland.
| | - Lars Buschhorn
- Sektion für Gynäkologische Onkologie, Nationales Centrum für Tumorerkrankungen (NCT), Heidelberg, Deutschland.
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8
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Abstract
High-throughput methods to investigate tumour omic landscapes have quickly catapulted cancer specialists into the precision oncology era. The singular lesson of precision oncology might be that, for it to be precise, treatment must be personalized, as each cancer's complex molecular and immune landscape differs from patient to patient. Transformative therapies include those that are targeted at the sequelae of molecular abnormalities or at immune mechanisms, and, increasingly, pathways previously thought to be undruggable have become druggable. Critical to applying precision medicine is the concept that the right combination of drugs must be chosen for each patient and used at the right stage of the disease. Multiple puzzles remain that complicate therapy choice, including evidence that deleterious mutations are common in normal tissues and non-malignant conditions. The host's role is also likely to be key in determining treatment response, especially for immunotherapy. Indeed, maximizing the impact of immunotherapy will require omic analyses to match the right immune-targeted drugs to the individualized patient and tumour setting. In this Perspective, we discuss six key riddles that must be solved to optimize the application of precision oncology to otherwise lethal malignancies.
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Affiliation(s)
- Adam Wahida
- Institute of Metabolism and Cell Death, Helmholtz Zentrum München, Neuherberg, Germany.
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany.
- Division of Molecular Genetics, German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany.
| | - Lars Buschhorn
- Division of Molecular Genetics, German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany.
| | - Stefan Fröhling
- Division of Translational Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Philipp J Jost
- Division of Clinical Oncology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Schneeweiss
- Division of Gynecological Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Peter Lichter
- Division of Molecular Genetics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Razelle Kurzrock
- WIN Consortium, Paris, France.
- Medical College of Wisconsin, Milwaukee, WI, USA.
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9
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Pixberg C, Zapatka M, Hlevnjak M, Benedetto S, Suppelna JP, Heil J, Smetanay K, Michel L, Fremd C, Körber V, Rübsam M, Buschhorn L, Heublein S, Schäfgen B, Golatta M, Gomez C, von Au A, Wallwiener M, Wolf S, Dikow N, Schaaf C, Gutjahr E, Allgäuer M, Stenzinger A, Pfütze K, Kirsten R, Hübschmann D, Sinn HP, Jäger D, Trumpp A, Schlenk R, Höfer T, Thewes V, Schneeweiss A, Lichter P. COGNITION: a prospective precision oncology trial for patients with early breast cancer at high risk following neoadjuvant chemotherapy. ESMO Open 2022; 7:100637. [PMID: 36423362 PMCID: PMC9808485 DOI: 10.1016/j.esmoop.2022.100637] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/09/2022] [Accepted: 10/18/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND COGNITION (Comprehensive assessment of clinical features, genomics and further molecular markers to identify patients with early breast cancer for enrolment on marker driven trials) is a diagnostic registry trial that employs genomic and transcriptomic profiling to identify biomarkers in patients with early breast cancer with a high risk for relapse after standard neoadjuvant chemotherapy (NACT) to guide genomics-driven targeted post-neoadjuvant therapy. PATIENTS AND METHODS At National Center for Tumor Diseases Heidelberg patients were biopsied before starting NACT, and for patients with residual tumors after NACT additional biopsy material was collected. Whole-genome/exome and transcriptome sequencing were applied on tumor and corresponding blood samples. RESULTS In the pilot phase 255 patients were enrolled, among which 213 were assessable: thereof 48.8% were identified to be at a high risk for relapse following NACT; 86.4% of 81 patients discussed in the molecular tumor board were eligible for a targeted therapy within the interventional multiarm phase II trial COGNITION-GUIDE (Genomics-guided targeted post neoadjuvant therapy in patients with early breast cancer) starting enrolment in Q4/2022. An in-depth longitudinal analysis at baseline and in residual tumor tissue of 16 patients revealed some cases with clonal evolution but largely stable genetic alterations, suggesting restricted selective pressure of broad-acting cytotoxic neoadjuvant chemotherapies. CONCLUSIONS While most precision oncology initiatives focus on metastatic disease, the presented concept offers the opportunity to empower novel therapy options for patients with high-risk early breast cancer in the post-neoadjuvant setting within a biomarker-driven trial and provides the basis to test the value of precision oncology in a curative setting with the overarching goal to increase cure rates.
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Affiliation(s)
- C Pixberg
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; University Hospital Heidelberg, Heidelberg, Germany
| | - M Zapatka
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; Division of Molecular Genetics, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany
| | - M Hlevnjak
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; Division of Molecular Genetics, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany; Research Group Computational Oncology, Molecular Precision Oncology Program, National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany
| | - S Benedetto
- Division of Theoretical Systems Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - J P Suppelna
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; University Hospital Heidelberg, Heidelberg, Germany
| | - J Heil
- Department of Obstetrics and Gynecology, Medical School, University of Heidelberg, Heidelberg, Germany
| | - K Smetanay
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; University Hospital Heidelberg, Heidelberg, Germany; Department of Obstetrics and Gynecology, Medical School, University of Heidelberg, Heidelberg, Germany
| | - L Michel
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; University Hospital Heidelberg, Heidelberg, Germany
| | - C Fremd
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; University Hospital Heidelberg, Heidelberg, Germany; Department of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, University Hospital Heidelberg, Heidelberg, Germany
| | - V Körber
- Division of Theoretical Systems Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - M Rübsam
- Research Group Computational Oncology, Molecular Precision Oncology Program, National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany
| | - L Buschhorn
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; University Hospital Heidelberg, Heidelberg, Germany
| | - S Heublein
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; University Hospital Heidelberg, Heidelberg, Germany; Department of Obstetrics and Gynecology, Medical School, University of Heidelberg, Heidelberg, Germany
| | - B Schäfgen
- Department of Obstetrics and Gynecology, Medical School, University of Heidelberg, Heidelberg, Germany
| | - M Golatta
- Department of Obstetrics and Gynecology, Medical School, University of Heidelberg, Heidelberg, Germany
| | - C Gomez
- Department of Obstetrics and Gynecology, Medical School, University of Heidelberg, Heidelberg, Germany
| | - A von Au
- Department of Obstetrics and Gynecology, Medical School, University of Heidelberg, Heidelberg, Germany
| | - M Wallwiener
- Department of Obstetrics and Gynecology, Medical School, University of Heidelberg, Heidelberg, Germany
| | - S Wolf
- Genomics and Proteomics Core Facility, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - N Dikow
- Institute of Human Genetics, Heidelberg University Hospital, Heidelberg, Germany
| | - C Schaaf
- Institute of Human Genetics, Heidelberg University Hospital, Heidelberg, Germany
| | - E Gutjahr
- Department of General Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - M Allgäuer
- Department of General Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - A Stenzinger
- Department of General Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - K Pfütze
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany
| | - R Kirsten
- Liquid Biobank, National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany
| | - D Hübschmann
- German Cancer Consortium (DKTK), Heidelberg, Germany; Research Group Computational Oncology, Molecular Precision Oncology Program, National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; Heidelberg Institute for Stem Cell Technology and Experimental Medicine (HI-STEM gGmbH), Heidelberg, Germany
| | - H-P Sinn
- Department of General Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - D Jäger
- Department of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, University Hospital Heidelberg, Heidelberg, Germany
| | - A Trumpp
- Heidelberg Institute for Stem Cell Technology and Experimental Medicine (HI-STEM gGmbH), Heidelberg, Germany; Division of Stem Cells and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - R Schlenk
- Department of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, University Hospital Heidelberg, Heidelberg, Germany; Department of Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany; NCT Trial Center, National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center and DKFZ, Heidelberg, Germany
| | - T Höfer
- Division of Theoretical Systems Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - V Thewes
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; University Hospital Heidelberg, Heidelberg, Germany; Division of Molecular Genetics, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany
| | - A Schneeweiss
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; University Hospital Heidelberg, Heidelberg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - P Lichter
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Medical Center, Heidelberg, Germany; Division of Molecular Genetics, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany.
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10
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Odinius TO, Buschhorn L, Wagner C, Hauch RT, Dill V, Dechant M, Buck MC, Shoumariyeh K, Moog P, Schwaab J, Reiter A, Brockow K, Götze K, Bassermann F, Höckendorf U, Branca C, Jost PJ, Jilg S. Comprehensive characterization of central BCL-2 family members in aberrant eosinophils and their impact on therapeutic strategies. J Cancer Res Clin Oncol 2021; 148:331-340. [PMID: 34654952 PMCID: PMC8800915 DOI: 10.1007/s00432-021-03827-9] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022]
Abstract
Purpose Hypereosinophilia represents a heterogenous group of severe medical conditions characterized by elevated numbers of eosinophil granulocytes in peripheral blood, bone marrow or tissue. Treatment options for hypereosinophilia remain limited despite recent approaches including IL-5-targeted monoclonal antibodies and tyrosine kinase inhibitors. Methods To understand aberrant survival patterns and options for pharmacologic intervention, we characterized BCL-2-regulated apoptosis signaling by testing for BCL-2 family expression levels as well as pharmacologic inhibition using primary patient samples from diverse subtypes of hypereosinophilia (hypereosinophilic syndrome n = 18, chronic eosinophilic leukemia not otherwise specified n = 9, lymphocyte-variant hypereosinophilia n = 2, myeloproliferative neoplasm with eosinophilia n = 2, eosinophilic granulomatosis with polyangiitis n = 11, reactive eosinophilia n = 3). Results Contrary to published literature, we found no difference in the levels of the lncRNA Morrbid and its target BIM. Yet, we identified a near complete loss of expression of pro-apoptotic PUMA as well as a reduction in anti-apoptotic BCL-2. Accordingly, BCL-2 inhibition using venetoclax failed to achieve cell death induction in eosinophil granulocytes and bone marrow mononuclear cells from patients with hypereosinophilia. In contrast, MCL1 inhibition using S63845 specifically decreased the viability of bone marrow progenitor cells in patients with hypereosinophilia. In patients diagnosed with Chronic Eosinophilic Leukemia (CEL-NOS) or Myeloid and Lymphatic Neoplasia with hypereosinophilia (MLN-Eo) repression of survival was specifically powerful. Conclusion Our study shows that MCL1 inhibition might be a promising therapeutic option for hypereosinophilia patients specifically for CEL-NOS and MLN-Eo. Supplementary Information The online version contains supplementary material available at 10.1007/s00432-021-03827-9.
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Affiliation(s)
- Timo O Odinius
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
- Centre for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
| | - Lars Buschhorn
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
- Centre for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
| | - Celina Wagner
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
- Centre for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
| | - Richard T Hauch
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
| | - Veronika Dill
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
- Centre for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
| | - Marta Dechant
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
- Centre for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
| | - Michele C Buck
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
| | - Khalid Shoumariyeh
- Department of Medicine I, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg Im Breisgau, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, Freiburg im Breisgau, Germany
| | - Philipp Moog
- Department of Nephrology, Clinic and Policlinic for Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Katharina Götze
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
| | - Florian Bassermann
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
- Centre for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
| | - Ulrike Höckendorf
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
- Centre for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
| | - Caterina Branca
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
- Centre for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany
| | - Philipp J Jost
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany.
- Centre for Translational Cancer Research (TranslaTUM), School of Medicine, Technical University of Munich, Munich, Germany.
- Division of Clinical Oncology, Department of Medicine, Medical University of Graz, Graz, Austria.
| | - Stefanie Jilg
- Clinic and Policlinic for Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany.
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11
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Dill V, Kauschinger J, Hauch RT, Buschhorn L, Odinius TO, Müller-Thomas C, Mishra R, Kyncl MC, Schmidt B, Prodinger PM, Hempel D, Bellos F, Höllein A, Kern W, Haferlach T, Slotta-Huspenina J, Bassermann F, Peschel C, Götze KS, Waizenegger IC, Höckendorf U, Jost PJ, Jilg S. Inhibition of PLK1 by capped-dose volasertib exerts substantial efficacy in MDS and sAML while sparing healthy haematopoiesis. Eur J Haematol 2020; 104:125-137. [PMID: 31758597 DOI: 10.1111/ejh.13354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Targeting the cell cycle machinery represents a rational therapeutic approach in myelodysplastic syndromes (MDS) and secondary acute myeloid leukemia (sAML). Despite substantial response rates, clinical use of the PLK inhibitor volasertib has been hampered by elevated side effects such as neutropenia and infections. OBJECTIVES The primary objective was to analyse whether a reduced dose of volasertib was able to limit toxic effects on the healthy haematopoiesis while retaining its therapeutic effect. METHODS Bone marrow mononuclear cells (BMMNCs) of patients with MDS/sAML (n = 73) and healthy controls (n = 28) were treated with volasertib (1 μM to 1 nM) or vehicle control. Short-term viability analysis was performed by flow cytometry after 72 hours. For long-term viability analysis, colony-forming capacity was assessed after 14 days. Protein expression of RIPK3 and MCL-1 was quantified via flow cytometry. RESULTS Reduced dose levels of volasertib retained high cell death-inducing efficacy in primary human stem and progenitor cells of MDS/sAML patients without affecting healthy haematopoiesis in vitro. Interestingly, volasertib reduced colony-forming capacity and cell survival independent of clinical stage or mutational status. CONCLUSIONS Volasertib offers a promising therapeutic approach in patients with adverse prognostic profile. RIPK3 and MCL-1 might be potential biomarkers for sensitivity to volasertib treatment.
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Affiliation(s)
- Veronika Dill
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Johanna Kauschinger
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Richard T Hauch
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Lars Buschhorn
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Timo O Odinius
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Catharina Müller-Thomas
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Ritu Mishra
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Center for Translational Cancer Research (TranslaTUM), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Michele C Kyncl
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Peter M Prodinger
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Dirk Hempel
- Onkologiezentrum Donauwörth, Donauworth, Germany
| | | | | | | | | | - Julia Slotta-Huspenina
- Institute of Pathology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Florian Bassermann
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Center for Translational Cancer Research (TranslaTUM), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- German Cancer Consortium (DKTK), DKFZ, Heidelberg, Germany
| | - Christian Peschel
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Katharina S Götze
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Ulrike Höckendorf
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Philipp J Jost
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Center for Translational Cancer Research (TranslaTUM), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- German Cancer Consortium (DKTK), DKFZ, Heidelberg, Germany
| | - Stefanie Jilg
- Medical Department III for Haematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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12
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Jilg S, Hauch RT, Kauschinger J, Buschhorn L, Odinius TO, Dill V, Müller-Thomas C, Herold T, Prodinger PM, Schmidt B, Hempel D, Bassermann F, Peschel C, Götze KS, Höckendorf U, Haferlach T, Jost PJ. Venetoclax with azacitidine targets refractory MDS but spares healthy hematopoiesis at tailored dose. Exp Hematol Oncol 2019; 8:9. [PMID: 31016067 PMCID: PMC6469098 DOI: 10.1186/s40164-019-0133-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 01/18/2019] [Accepted: 04/04/2019] [Indexed: 11/24/2022] Open
Abstract
Patients with Myelodysplastic Syndromes (MDS) and secondary Acute Myeloid Leukemia (sAML) have a very poor prognosis after failure of hypomethylating agents (HMA). Stem cell transplantation is the only effective salvage therapy, for which only a limited number of patients are eligible due to age and comorbidity. Combination therapy of venetoclax and azacitidine (5-AZA) seems to be a promising approach in myeloid malignancies, but data from patients with HMA failure are lacking. Furthermore, a considerable concern of combination regimens in elderly AML and MDS patients is the toxicity on the remaining healthy hematopoiesis. Here, we report in vitro data showing the impact of venetoclax and 5-AZA, alone or in combination, in a larger cohort of MDS/sAML patients (n = 21), even after HMA failure (n = 13). We especially focused on the effects on healthy hematopoiesis and the impact on colony forming capacity as a parameter for long-term effects. To the best of our knowledge, we show for the first time that venetoclax in combination with capped dose of 5-AZA targets cell malignancies, while sparing healthy hematopoiesis.
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Affiliation(s)
- Stefanie Jilg
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Richard T Hauch
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Johanna Kauschinger
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Lars Buschhorn
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Timo O Odinius
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Veronika Dill
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Catharina Müller-Thomas
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Tobias Herold
- 2Department of Internal Medicine 3, University Hospital Grosshadern, Ludwig-Maximilians-Universität (LMU), 81377 Munich, Germany
| | - Peter M Prodinger
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Dirk Hempel
- Onkologisches Zentrum Donauwörth, Donauwörth, Germany
| | - Florian Bassermann
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany.,6German Consortium for Translational Cancer Research (DKTK) of the German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Peschel
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany.,6German Consortium for Translational Cancer Research (DKTK) of the German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Katharina S Götze
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany.,6German Consortium for Translational Cancer Research (DKTK) of the German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ulrike Höckendorf
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany
| | | | - Philipp J Jost
- Medical Department III for Hematology and Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany.,6German Consortium for Translational Cancer Research (DKTK) of the German Cancer Research Center (DKFZ), Heidelberg, Germany
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