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The role of randomized controlled trials, registries, observational databases in evaluating new interventions 随机对照试验、登记、观察性数据库在评估新干预措施中的作用
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-31 DOI: 10.1016/j.beha.2023.101523
Robert Peter Gale , Mei-Jie Zhang , Hillard M. Lazarus

Approaches to comparing safety and efficacy of interventions include analyzing data from randomized controlled trials (RCTs), registries and observational databases (ODBs). RCTs are regarded as the gold standard but data from such trials are sometimes unavailable because a disease is uncommon, because the intervention is uncommon, because of structural limitations or because randomization cannot be done for practical or (seemingly) ethical reasons. There are many examples of an unproved intervention being so widely-believed to be effective that clinical trialists and potential subjects decline randomization. Often, when a RCT is finally done the intervention is proved ineffective or even harmful. These situations are termed medical reversals and are not uncommon [1,2]. There is also the dilemma of when seemingly similar RCTs report discordant conclisions

Data from high-quality registries, especially ODBs can be used when data from RCTs are unavailable but also have limitations. Biases and confounding co-variates may be unknown, difficult or impossible to identify and/or difficult to adjust for adequately. However, ODBs sometimes have large numbers of diverse subjects and often give answers more useful to clinicians than RCTs. Side-by-side comparisons suggest analyses from high-quality ODBs often give similar conclusions from high quality RCTs. Meta-analyses combining data from RCTs, registries and ODBs are sometimes appropriate. We suggest increased use of registries and ODBs to compare efficacy of interventions.

比较干预措施的安全性和有效性的方法包括分析来自随机对照试验(rct)、登记和观察数据库(odb)的数据。随机对照试验被视为金标准,但由于疾病不常见、干预措施不常见、结构限制或由于实际或(看似)伦理原因无法进行随机化,有时无法获得此类试验的数据。有许多未经证实的干预措施被广泛认为是有效的,以至于临床试验人员和潜在受试者拒绝随机化。通常,当随机对照试验最终完成时,干预被证明是无效的,甚至是有害的。这些情况被称为医学逆转,并不罕见[1,2]。当看似相似的随机对照试验报告不一致的结论时,也存在两难境地。当随机对照试验的数据不可用但也有局限性时,可以使用来自高质量注册中心的数据,特别是odb。偏差和混杂协变量可能是未知的,难以或不可能识别和/或难以充分调整。然而,odb有时有大量不同的受试者,通常比随机对照试验提供的答案对临床医生更有用。并排比较表明,来自高质量odb的分析往往得出与高质量rct相似的结论。结合随机对照试验、注册表和odb的数据进行meta分析有时是合适的。我们建议增加使用登记处和odb来比较干预措施的有效性。
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引用次数: 0
The international cooperative Gaucher group (ICCG) Gaucher registry 国际合作戈歇组织(ICCG)戈歇注册
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-31 DOI: 10.1016/j.beha.2023.101522
Neal J. Weinreb

Gaucher disease GD), is a rare lysosomal storage disorder caused by deficient acid β-glucosylceramidase activity and accumulation of glucosylceramide in tissue macrophages. With the 1991 advent of alglucerase enzyme replenishment therapy (ERT), the manufacturer (Genzyme Corporation) created the ICGG Gaucher Registry to collect longitudinal observational “real word” information about GD world-wide in heterogeneous patient populations, to annotate phenotypes and genotypes that define the natural history of GD in untreated patients, and to document and analyze treatment outcomes for alglucerase and any other future treatments. For 32 years, the ICGG Gaucher Registry has functioned as an educational tool for patients, clinicians, and other stakeholders to increase scientific knowledge of GD, to provide practical management guidance, and to positively impact patient care. This paper illustrates how an industry sponsored registry guided by a company independent scientific advisory board has successfully addressed its mission and evolved in step with technologic and scientific advances.

戈谢病是一种罕见的溶酶体贮积性疾病,由酸性β-葡萄糖神经酰胺酶活性不足和组织巨噬细胞中葡萄糖神经酰胺的积累引起。随着1991年醛糖酶补充疗法(ERT)的出现,制造商(Genzyme Corporation)创建了ICGG Gaucher Registry,以收集全球异质患者群体中关于GD的纵向观察“真实单词”信息,注释表型和基因型,定义未治疗患者GD的自然历史,并记录和分析醛糖酶和任何其他未来治疗的治疗结果。32年来,ICGG Gaucher Registry一直是患者、临床医生和其他利益相关者的教育工具,以增加GD的科学知识,提供实用的管理指导,并积极影响患者护理。本文阐述了一个由公司独立的科学顾问委员会指导的行业赞助的注册表是如何成功地完成其使命,并与技术和科学进步同步发展的。
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引用次数: 0
The Australian Aplastic Anaemia and other Bone Marrow Failure Syndromes Registry 澳大利亚再生障碍性贫血和其他骨髓衰竭综合征登记处
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-23 DOI: 10.1016/j.beha.2023.101516
Lucy C. Fox , Zoe K. McQuilten , Frank Firkin , Vanessa Fox , Xavier Badoux , Ashish Bajel , Pasquale Barbaro , Merrole F. Cole-Sinclair , Cecily Forsyth , John Gibson , Devendra K. Hiwase , Anna Johnston , Anthony Mills , Fernando Roncolato , Robyn Sutherland , Jeff Szer , Stephen B. Ting , Shahla Vilcassim , Lauren Young , Neil A. Waters , Erica M. Wood

The bone marrow failure syndromes (BMFS) are a diverse group of acquired and inherited diseases which may manifest in cytopenias, haematological malignancy and/or syndromic multisystem disease. Patients with BMFS frequently experience poor outcomes, and improved treatment strategies are needed. Collation of clinical characteristics and patient outcomes in a national disease-specific registry represents a powerful tool to identify areas of need and support clinical and research collaboration. Novel treatment strategies such as gene therapy, particularly in rare diseases, will depend on the ability to identify eligible patients alongside the molecular genetic features of their disease that may be amenable to novel therapy. The Australian Aplastic Anaemia and other Bone Marrow Failure Syndromes Registry (AAR) aims to improve outcomes for all paediatric and adult patients with BMFS in Australia by describing the demographics, treatments (including supportive care) and outcomes, and serving as a resource for research and practice improvement.

骨髓衰竭综合征(BMFS)是一组不同的获得性和遗传性疾病,可能表现为细胞减少、血液恶性肿瘤和/或综合征性多系统疾病。BMFS患者往往预后不佳,需要改进治疗策略。在国家疾病特异性登记中整理临床特征和患者结果是确定需要领域并支持临床和研究合作的有力工具。新的治疗策略,如基因治疗,特别是在罕见疾病中,将取决于识别符合条件的患者及其疾病的分子遗传特征的能力,这些特征可能适用于新的治疗方法。澳大利亚再生障碍性贫血和其他骨髓衰竭综合征登记处(AAR)旨在通过描述人口统计学、治疗(包括支持性护理)和结果,并作为研究和实践改进的资源,改善澳大利亚所有患有BMFS的儿科和成人患者的结局。
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引用次数: 0
WHO, what, when, where, and why: New classification systems for acute myeloid leukemia and their impact on clinical practice WHO, What, When, Where, and Why:急性髓性白血病的新分类系统及其对临床实践的影响
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-20 DOI: 10.1016/j.beha.2023.101518
Frederick R. Appelbaum

The goal of a disease classification system is (or should be) to provide a tool for researchers and clinicians to study and treat the disease. The last decade has seen a markedly improved understanding of the pathophysiology of acute myeloid leukemia (AML), the development of new methods to measure the disease, and approval by the Food and Drug Administration (FDA) of at least ten new therapies targeted to its treatment. In response, in 2022 one updated and one new AML classification system were published. In the same year, the European LeukemiaNet updated their recommendations about how to incorporate the advances in diagnosis and treatment into the risk stratification of AML and its treatment. The following discussion summarizes the highlights of these changes and offers an opinion of how well these changes meet the goal of aiding researchers and clinicians in the study and treatment of AML.

疾病分类系统的目标是(或应该是)为研究人员和临床医生提供研究和治疗疾病的工具。在过去的十年中,人们对急性髓性白血病(AML)的病理生理学有了显著的了解,新的疾病测量方法得到了发展,美国食品和药物管理局(FDA)批准了至少十种针对其治疗的新疗法。作为回应,2022年发布了一个更新的和一个新的“反洗钱”分类系统。同年,欧洲白血病网络更新了关于如何将诊断和治疗方面的进展纳入AML及其治疗的风险分层的建议。下面的讨论总结了这些变化的亮点,并提出了这些变化在多大程度上满足了帮助研究人员和临床医生研究和治疗AML的目标。
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引用次数: 0
The best GVHD prophylaxis: Or at least progress towards finding it 最好的GVHD预防方法:或者至少朝着找到它的方向前进
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-20 DOI: 10.1016/j.beha.2023.101520
Daniel Weisdorf , Najla El Jurdi , Shernan G. Holtan

Options for GVHD prophylaxis after allogeneic hematopoietic cell transplantation can best be chosen by understanding the pathophysiology of GVHD. Interventions to limit T cell activation, expansion and subsequent tissue injury can each be utilized in designing successful GVHD prevention strategies Depleting, tolerizing or blunting T cells or host antigen presenting cells (APCs), blocking co-stimulation or more broadly suppressing inflammation have all been used. Interventions which spare regulatory T cells (Tregs) may prevent GVHD and facilitate controlled allo-responses and not compromise subsequent relapse risks. Graft manipulations and pharmacologic interventions each have potential to limit the morbidity of GVHD while permitting the immunocompetence to prevent infection or relapse.

同种异体造血细胞移植后预防GVHD的选择最好是通过了解GVHD的病理生理机制来选择。限制T细胞活化、扩增和随后的组织损伤的干预措施都可以用于设计成功的GVHD预防策略,消耗、耐受或钝化T细胞或宿主抗原呈递细胞(apc),阻断共刺激或更广泛地抑制炎症都已被使用。不使用调节性T细胞(Tregs)的干预措施可以预防GVHD,促进可控的同种异体反应,并且不会降低随后的复发风险。移植物操作和药物干预都有可能限制GVHD的发病率,同时允许免疫能力预防感染或复发。
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引用次数: 0
Mechanisms of resistance to hypomethylating agents and BCL-2 inhibitors 对低甲基化药物和BCL-2抑制剂的耐药性机制
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-20 DOI: 10.1016/j.beha.2023.101521
Sudhamsh Reddy Desai , Samarpana Chakraborty , Aditi Shastri

Myeloid malignancies such as myelodysplastic syndrome (MDS) & acute myeloid leukemia (AML) are clonal diseases that emerge and progress due to the expansion of disease-initiating aberrant hematopoietic stem cells, that are not eliminated by conventional cytotoxic therapies. Hypomethylating agents(HMA), azacytidine and decitabine are the first line agents for treatment of MDS and a combination with BCL-2 inhibitor, venetoclax, is approved for AML induction in patients above 75 years and is also actively being investigated for use in high risk MDS. Resistance to these drugs has become a significant clinical challenge in treatment of myeloid malignancies. In this review, we discuss molecular mechanisms underlying the development of resistance to HMA and venetoclax. Insights into these mechanisms can help identify potential biomarkers for resistance prediction, aid in the development of combination therapies and strategies to prevent resistance and advance the field of cancer therapeutics.

髓系恶性肿瘤,如骨髓增生异常综合征(MDS);急性髓性白血病(AML)是由于引起疾病的异常造血干细胞的扩张而出现和发展的克隆性疾病,传统的细胞毒性治疗无法消除。低甲基化药物(HMA)、阿扎胞苷(azacytidine)和地西他滨(decitabine)是治疗MDS的一线药物,与BCL-2抑制剂venetoclax联合被批准用于75岁以上患者的AML诱导,同时也在积极研究用于高风险MDS的药物。对这些药物的耐药性已成为髓系恶性肿瘤治疗的一个重大临床挑战。在这篇综述中,我们讨论了HMA和venetoclax耐药发展的分子机制。深入了解这些机制有助于识别潜在的耐药预测生物标志物,有助于开发联合疗法和预防耐药的策略,并推动癌症治疗领域的发展。
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引用次数: 0
When to use which molecular prognostic scoring system in the management of patients with MDS? 在MDS患者的管理中,何时使用哪种分子预后评分系统?
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-17 DOI: 10.1016/j.beha.2023.101517
Tariq Kewan , Jan Philipp Bewersdorf , Carmelo Gurnari , Zhuoer Xie , Maximilian Stahl , Amer M. Zeidan

Myelodysplastic syndromes/neoplasms (MDS) are a heterogeneous group of hematopoietic cancers characterized by recurrent molecular alterations driving the disease pathogenesis with a variable propensity for progression to acute myeloid leukemia (AML). Clinical decision making for MDS relies on appropriate risk stratification at diagnosis, with higher-risk patients requiring more intensive therapy. The conventional clinical prognostic systems including the International Prognostic Scoring System (IPSS) and its revised version (IPSS-R) have dominated the risk stratification of MDS from 1997 until 2022. Concurrently, the use of next-generation sequencing has revolutionized the field by revealing multiple recurrent genetic mutations, which correlate with phenotype and prognosis. Significant efforts have been made to formally incorporate molecular data into prognostic tools to improve proper risk identification and personalize treatment strategies. In this review, we will critically compare the available molecular scoring systems for MDS focusing on areas of progress and potential limitations that can be improved in subsequent revisions of these tools.

骨髓增生异常综合征/肿瘤(MDS)是一组异质性造血癌症,其特征是复发性分子改变驱动疾病发病机制,具有发展为急性髓系白血病(AML)的可变倾向。MDS的临床决策依赖于诊断时适当的风险分层,高风险患者需要更强化的治疗。从1997年到2022年,包括国际预后评分系统(IPSS)及其修订版本(IPSS- r)在内的传统临床预后系统主导了MDS的风险分层。同时,下一代测序的使用通过揭示与表型和预后相关的多种复发性基因突变,彻底改变了该领域。在将分子数据正式纳入预后工具以改进适当的风险识别和个性化治疗策略方面已经做出了重大努力。在这篇综述中,我们将批判性地比较现有的MDS分子评分系统,重点关注这些工具在后续修订中可以改进的进展和潜在局限性。
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引用次数: 0
Asparaginase dosing for obese patients with acute lymphoblastic leukemia and factors that contribute to outcomes 急性淋巴细胞白血病肥胖患者的天冬酰胺酶剂量和影响结果的因素
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-14 DOI: 10.1016/j.beha.2023.101519
Ryan D. Cassaday

Asparaginase in various forms is a standard part of the treatment of acute lymphoblastic leukemia (ALL) in children and adolescents. However, its use is more selective in adults. One of the key reasons is the toxicity observed from this class of agents. In a series of recent post hoc analyses of large prospective studies, obesity has emerged as a key factor that contributes to the challenges with administering regimens that include asparaginase. In this review, the most salient findings are highlighted from these latest publications, both from the pediatric and adult literature. These data are consolidated into recommendations for clinicians who treat adults with ALL, including proposals for how treatment may be modified to try to account for these complications. Lastly, avenues for future investigation are proposed in an attempt to narrow our knowledge gaps in this field, with the goal of safer and more effective treatment for adults with obesity who develop ALL.

各种形式的天冬酰胺酶是儿童和青少年急性淋巴细胞白血病(ALL)治疗的标准部分。然而,它在成人中的使用更具选择性。其中一个关键原因是从这类药剂中观察到的毒性。在最近一系列大型前瞻性研究的事后分析中,肥胖已成为导致包括天冬酰胺酶在内的管理方案面临挑战的关键因素。在这篇综述中,从这些最新的出版物中突出了最突出的发现,包括儿童和成人文献。这些数据被整合为临床医生治疗成人ALL患者的建议,包括如何修改治疗以试图解释这些并发症的建议。最后,提出了未来研究的途径,试图缩小我们在这一领域的知识差距,目标是更安全,更有效地治疗成人肥胖发展为ALL。
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引用次数: 0
Cytogenomics of B-cell non-Hodgkin lymphomas: The “old” meets the “new” b细胞非霍奇金淋巴瘤的细胞基因组学:“老”与“新”的相遇
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-10 DOI: 10.1016/j.beha.2023.101513
Marta Grau , Cristina López , José Ignacio Martín-Subero , Sílvia Beà

For the routine diagnosis of haematological neoplasms an integrative approach is used considering the morphology, and the immunophenotypic, and molecular features of the tumor sample, along with clinical information. The identification and characterization of recurrent chromosomal aberrations mainly detected by conventional and molecular cytogenetics in the tumor cells has a major impact on the classification of lymphoid neoplasms. Some of the B-cell non-Hodgkin lymphomas are characterized by particular chromosomal aberrations, highlighting the relevance of conventional and molecular cytogenetic studies in their diagnosis and prognosis. In the current genomics era, next generation sequencing provides relevant information as the mutational profiles of haematological malignancies, improving their classification and also the clinical management of the patients. In addition, other new technologies have emerged recently, such as the optical genome mapping, which can overcome some of the limitations of conventional and molecular cytogenetics and may become more widely used in the cytogenetic laboratories in the upcoming years. Moreover, epigenetic alterations may complement genetic changes for a deeper understanding of the pathogenesis underlying B-cell neoplasms and a more precise risk-based patient stratification. Overall, here we describe the current state of the genomic data integrating chromosomal rearrangements, copy number alterations, and somatic variants, as well as a succinct overview of epigenomic changes, which altogether constitute a comprehensive diagnostic approach in B-cell non-Hodgkin lymphomas.

对于血液肿瘤的常规诊断,使用综合方法,考虑肿瘤样本的形态学、免疫表型和分子特征以及临床信息。主要通过常规和分子细胞遗传学在肿瘤细胞中检测到的复发性染色体畸变的鉴定和表征对淋巴肿瘤的分类具有重要影响。一些B细胞非霍奇金淋巴瘤以特定的染色体畸变为特征,突出了常规和分子细胞遗传学研究在其诊断和预后中的相关性。在当前的基因组学时代,下一代测序提供了相关信息,如血液系统恶性肿瘤的突变谱,改善了它们的分类以及患者的临床管理。此外,最近还出现了其他新技术,如光学基因组图谱,它可以克服传统和分子细胞遗传学的一些局限性,并可能在未来几年在细胞遗传学实验室中得到更广泛的应用。此外,表观遗传学改变可能补充遗传变化,以更深入地了解B细胞肿瘤的发病机制,并更准确地进行基于风险的患者分层。总的来说,我们在这里描述了基因组数据的现状,包括染色体重排、拷贝数改变和体细胞变异,以及表观基因组变化的简要概述,这些数据共同构成了B细胞非霍奇金淋巴瘤的综合诊断方法。
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引用次数: 0
Hodgkin Lymphoma: A disease shaped by the tumor micro- and macroenvironment 霍奇金淋巴瘤:一种由肿瘤微观和宏观环境形成的疾病
IF 2.1 4区 医学 Q2 Medicine Pub Date : 2023-10-07 DOI: 10.1016/j.beha.2023.101514
Rebecca Masel , Megan E. Roche , Ubaldo Martinez-Outschoorn

The tumor microenvironment (TMicroE) and tumor macroenvironment (TMacroE) are defining features of classical Hodgkin lymphoma (cHL). They are of critical importance to clinicians since they explain the common signs and symptoms, allow us to classify these neoplasms, develop prognostic and predictive biomarkers, bioimaging and novel treatments. The TMicroE is defined by effects of cancer cells to their immediate surrounding and within the tumor. Effects of cancer cells at a distance or outside of the tumor define the TMacroE. Paraneoplastic syndromes are signs and symptoms due to effects of cancer at a distance or the TMacroE, which are not due to direct cancer cell infiltration. The most common paraneoplastic symptoms are B-symptoms, which manifest as fevers, chills, drenching night sweats, and/or weight loss. Less common paraneoplastic syndromes include those that affect the central nervous system, skin, kidney, and hematological autoimmune phenomena including hemophagocytic lymphohistiocytosis (HLH). Paraneoplastic signs such as leukocytosis, lymphopenia, anemia, and hypoalbuminemia are prognostic biomarkers. The neoplastic cells in cHL are the Hodgkin and Reed Sternberg (HRS) cells, which are preapoptotic germinal center B cells with a high mutational burden and almost universal genetic alterations at the 9p24.1 locus primarily through copy gain and amplification with strong activation of signaling via PD-L1, JAK-STAT, NFkB, and c-MYC. In the majority of cases of cHL over 95% of the tumor cells are non-neoplastic. In the TMicroE, HRS cells recruit and mold non-neoplastic cells vigorously via extracellular vesicles, chemokines, cytokines and growth factors such as CCL5, CCL17, IL6, and TGF-β to promote a feed-forward inflammatory loop, which drives cancer aggressiveness and anti-cancer immune evasion. Novel single cell profiling techniques provide critical information on the role in cHL of monocytes-macrophages, neutrophils, T helper, Tregs, cytotoxic CD8+ T cells, eosinophils, mast cells and fibroblasts. Here, we summarize the effects of EBV on the TMicroE and TMacroE. In addition, how the metabolism of the TMicroE of cHL affects bioimaging and contributes to cancer aggressiveness is reviewed. Finally, we discuss how the TMicroE is being leveraged for risk adapted treatment strategies based on bioimaging results and novel immune therapies. In sum, it is clear that we cannot effectively manage patients with cHL without understanding the TMicroE and TMacroE and its clinical importance is expected to continue to grow rapidly.

肿瘤微环境(TMicroE)和肿瘤大环境(TMacroE)是典型霍奇金淋巴瘤(cHL)的特征。它们对临床医生来说至关重要,因为它们解释了常见的体征和症状,使我们能够对这些肿瘤进行分类,开发预后和预测性生物标志物,生物成像和新的治疗方法。TMicroE是指癌症细胞对其周围和肿瘤内的影响。癌症细胞在肿瘤远处或外部的作用定义了TMacroE。副肿瘤综合征是由远处癌症或TMacroE影响引起的体征和症状,而不是由癌症细胞直接浸润引起的。最常见的副肿瘤症状是B症状,表现为发烧、发冷、盗汗和/或体重减轻。不太常见的副肿瘤综合征包括影响中枢神经系统、皮肤、肾脏和血液系统自身免疫现象的综合征,包括噬血细胞性淋巴组织细胞增多症(HLH)。白细胞增多、淋巴细胞减少、贫血和低白蛋白血症等副肿瘤体征是预后的生物标志物。cHL中的肿瘤细胞是霍奇金和Reed-Sternberg(HRS)细胞,它们是凋亡前生发中心B细胞,在9p24.1基因座上具有高突变负荷和几乎普遍的遗传改变,主要通过拷贝获得和扩增,并通过PD-L1、JAK-STAT、NFkB和c-MYC强激活信号。在大多数cHL病例中,超过95%的肿瘤细胞是非肿瘤性的。在TMicroE中,HRS细胞通过细胞外小泡、趋化因子、细胞因子和生长因子(如CCL5、CCL17、IL6和TGF-β)大力招募和塑造非肿瘤细胞,以促进前馈炎症循环,从而驱动癌症侵袭性和抗癌免疫逃避。新的单细胞图谱技术提供了关于单核细胞-巨噬细胞、中性粒细胞、辅助T细胞、Tregs、细胞毒性CD8+T细胞、嗜酸性粒细胞、肥大细胞和成纤维细胞在cHL中的作用的关键信息。在此,我们总结EBV对TMicroE和TMacroE的影响。此外,对cHL的TMicroE代谢如何影响生物成像并导致癌症侵袭性进行了综述。最后,我们讨论了TMicroE是如何根据生物成像结果和新型免疫疗法用于风险适应治疗策略的。总之,很明显,如果不了解TMicroE和TMacroE,我们就无法有效管理cHL患者,其临床重要性预计将继续快速增长。
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引用次数: 0
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Best Practice & Research Clinical Haematology
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