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Irikura T, Fukuoka K, Nakazawa A, Ichimura K, Kurihara J, Koh K. Molecular characterization of long-term survivors of metastatic medulloblastoma treated with reduced-dose craniospinal irradiation. Childs Nerv Syst 2023; 39:2505-2507. [PMID: 37185696 DOI: 10.1007/s00381-023-05971-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND AND AIMS Current standard treatment for metastatic medulloblastoma consists of 36 Gray (Gy) of craniospinal irradiation (CSI) supplemented with local irradiation and adjuvant chemotherapy after surgery. Although contemporary protocols have been designed to limit a radiation dose using risk-adapted CSI dosing to reduce neurocognitive morbidity, high-dose CSI remains the standard of care. Recently, the molecular classification of medulloblastoma has been emerging but its clinical significance has not been established particularly in patients with metastatic medulloblastoma treated with lower dose of CSI. METHODS We molecularly analyzed three cases of metastatic medulloblastoma treated with 24.0 Gy of CSI by DNA methylation analysis using the Illumina EPIC array. RESULTS All three patients had spinal metastases at the time of diagnosis. Postoperative treatment included multiple courses of chemotherapy, 24 Gy of CSI with focal boost to primary and metastatic sites, and high-dose chemotherapy. There was no disease progression observed during the 9.0, 7.7, and 5.7 years post-diagnosis follow-up. The molecular diagnosis was Group 3/4 in all three cases. Cases 1 and 2 belonged to Subtypes 7 and 4, both of which were reported to be good prognostic subtypes among the group. Case 3 belonged to Subtype 5 with MYC amplification. CONCLUSIONS The present cases suggest that the novel subtype classification in Group 3/4 medulloblastoma may be useful for risk stratification of patients with metastatic medulloblastoma who received lower dose of CSI than standard treatment.
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Affiliation(s)
- Tomoya Irikura
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Kohei Fukuoka
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan.
| | - Atsuko Nakazawa
- Department of Clinical Research, Saitama Children's Medical Center, Saitama, Japan
| | - Koichi Ichimura
- Department of Brain Disease Translational Research, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Jun Kurihara
- Department of Neurosurgery, Saitama Children's Medical Center, Saitama, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
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Perek-Polnik M, Cochrane A, Wang J, Chojnacka M, Drogosiewicz M, Filipek I, Swieszkowska E, Tarasinska M, Grajkowska W, Trubicka J, Kowalczyk P, Dembowska-Bagińskai B, Abdelbaki MS. Risk-Adapted Treatment Strategies with Pre-Irradiation Chemotherapy in Pediatric Medulloblastoma: Outcomes from the Polish Pediatric Neuro-Oncology Group. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1387. [PMID: 37628386 PMCID: PMC10453075 DOI: 10.3390/children10081387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023]
Abstract
Craniospinal irradiation (CSI) has been a major component of the standard of care treatment backbone for childhood medulloblastoma. However, chemotherapy regimens have varied based on protocol, patient age, and molecular subtyping. In one of the largest studies to date, we analyzed treatment outcomes in children with newly-diagnosed medulloblastoma treated with pre-irradiation chemotherapy followed by risk-adapted radiotherapy and maintenance chemotherapy. A total of 153 patients from the Polish Pediatric Neuro-Oncology Group were included in the analysis. The median age at diagnosis was 8.0 years, and median follow-up time was 6.4 years. Sixty-seven patients were classified as standard-risk and eighty-six as high-risk. Overall survival (OS) and event-free survival (EFS) for standard-risk patients at 5 years (±standard error) were 87 ± 4.3% and 84 ± 4.6%, respectively, while 5-year OS and EFS for high-risk patients were 81 ± 4.3% and 79 ± 4.5%, respectively. Only one patient had disease progression prior to radiotherapy. This study demonstrates promising survival outcomes in patients treated with pre-irradiation chemotherapy followed by risk-adapted CSI and adjuvant chemotherapy. Such an approach may be useful in cases where the initiation of radiotherapy may need to be delayed, a common occurrence in many institutions globally.
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Affiliation(s)
- Marta Perek-Polnik
- Department of Oncology, Children’s Memorial Health Institute, 01-211 Warsaw, Poland; (M.D.); (I.F.); (E.S.); (M.T.); (B.D.-B.)
| | - Anne Cochrane
- Division of Hematology and Oncology, Department of Pediatrics, School of Medicine, Washington University, St. Louis, MO 63110, USA
| | - Jinli Wang
- Center for Biostatistics and Data Science, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Marzanna Chojnacka
- Maria Sklodowska-Curie National Research Institute of Oncology, Pediatric Radiotherapy Centre, 00-001 Warsaw, Poland
| | - Monika Drogosiewicz
- Department of Oncology, Children’s Memorial Health Institute, 01-211 Warsaw, Poland; (M.D.); (I.F.); (E.S.); (M.T.); (B.D.-B.)
| | - Iwona Filipek
- Department of Oncology, Children’s Memorial Health Institute, 01-211 Warsaw, Poland; (M.D.); (I.F.); (E.S.); (M.T.); (B.D.-B.)
| | - Ewa Swieszkowska
- Department of Oncology, Children’s Memorial Health Institute, 01-211 Warsaw, Poland; (M.D.); (I.F.); (E.S.); (M.T.); (B.D.-B.)
| | - Magdalena Tarasinska
- Department of Oncology, Children’s Memorial Health Institute, 01-211 Warsaw, Poland; (M.D.); (I.F.); (E.S.); (M.T.); (B.D.-B.)
| | - Wiesława Grajkowska
- Department of Pathology, Children’s Memorial Health Institute, 01-211 Warsaw, Poland; (W.G.); (J.T.)
| | - Joanna Trubicka
- Department of Pathology, Children’s Memorial Health Institute, 01-211 Warsaw, Poland; (W.G.); (J.T.)
| | - Paweł Kowalczyk
- Department of Neurosurgery, Children’s Memorial Health Institute, 01-211 Warsaw, Poland;
| | - Bożenna Dembowska-Bagińskai
- Department of Oncology, Children’s Memorial Health Institute, 01-211 Warsaw, Poland; (M.D.); (I.F.); (E.S.); (M.T.); (B.D.-B.)
| | - Mohamed S. Abdelbaki
- Division of Hematology and Oncology, Department of Pediatrics, School of Medicine, Washington University, St. Louis, MO 63110, USA
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Osuna-Marco MP, Martín-López LI, Tejera ÁM, López-Ibor B. Questions and answers in the management of children with medulloblastoma over the time. How did we get here? A systematic review. Front Oncol 2023; 13:1229853. [PMID: 37456257 PMCID: PMC10340518 DOI: 10.3389/fonc.2023.1229853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Treatment of children with medulloblastoma (MB) includes surgery, radiation therapy (RT) and chemotherapy (CT). Several treatment protocols and clinical trials have been developed over the time to maximize survival and minimize side effects. Methods We performed a systematic literature search in May 2023 using PubMed. We selected all clinical trials articles and multicenter studies focusing on MB. We excluded studies focusing exclusively on infants, adults, supratentorial PNETs or refractory/relapsed tumors, studies involving different tumors or different types of PNETs without differentiating survival, studies including <10 cases of MB, solely retrospective studies and those without reference to outcome and/or side effects after a defined treatment. Results 1. The main poor-prognosis factors are: metastatic disease, anaplasia, MYC amplification, age younger than 36 months and some molecular subgroups. The postoperative residual tumor size is controversial.2. MB is a collection of diseases.3. MB is a curable disease at diagnosis, but survival is scarce upon relapse.4. Children should be treated by experienced neurosurgeons and in advanced centers.5. RT is an essential treatment for MB. It should be administered craniospinal, early and without interruptions.6. Craniospinal RT dose could be lowered in some low-risk patients, but these reductions should be done with caution to avoid relapses.7. Irradiation of the tumor area instead of the entire posterior fossa is safe enough.8. Hyperfractionated RT is not superior to conventional RT9. Both photon and proton RT are effective.10. CT increases survival, especially in high-risk patients.11. There are multiple drugs effective in MB. The combination of different drugs is appropriate management.12. CT should be administered after RT.13. The specific benefit of concomitant CT to RT is unknown.14. Intensified CT with stem cell rescue has no benefit compared to standard CT regimens.15. The efficacy of intraventricular/intrathecal CT is controversial.16. We should start to think about incorporating targeted therapies in front-line treatment.17. Survivors of MB still have significant side effects. Conclusion Survival rates of MB improved greatly from 1940-1970, but since then the improvement has been smaller. We should consider introducing targeted therapy as front-line therapy.
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Affiliation(s)
- Marta P. Osuna-Marco
- Pediatric Oncology Unit, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
- Faculty of Experimental Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | - Laura I. Martín-López
- Pediatric Oncology Unit, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
| | - Águeda M. Tejera
- Faculty of Experimental Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | - Blanca López-Ibor
- Pediatric Oncology Unit, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
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High-dose thiotepa, in conjunction with melphalan, followed by autologous hematopoietic stem cell transplantation in patients with pediatric solid tumors, including brain tumors. Bone Marrow Transplant 2023; 58:123-128. [PMID: 36329150 PMCID: PMC9902273 DOI: 10.1038/s41409-022-01820-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 06/15/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Abstract
Among pediatric malignancies, solid tumors, particularly within the central nervous system (CNS), are common. Thiotepa, a myeloablative, high-dose chemotherapeutic (HDT) treatment administered prior to autologous hematopoietic stem cell transplantation (HSCT), can cross the blood-brain barrier and rapidly penetrate the CNS. We evaluated thiotepa HDT in conjunction with melphalan in Japanese patients with pediatric CNS/non-CNS solid tumors in a multicenter, open-label, non-comparative study. Thiotepa (200 mg/m2/day) was administered intravenously (IV) over 24 h on days -12, -11, -5, and -4 before scheduled HSCT. Melphalan (70 mg/m2/day) was administered IV over 1 h on days -11, -5, and -4. The safety analysis population comprised 41 patients, of whom 16 (39.0%) had solid tumors and 25 (61.0%) had brain tumors. The most frequently reported adverse events were diarrhea (40/41 [97.6%] patients) and febrile neutropenia (34/41 [82.9%]). No unexpected safety events were observed, and no events resulted in death or treatment discontinuation. All patients experienced bone marrow suppression and 39/41 (95.1%) achieved engraftment (neutrophil count ≥500/mm3 for 3 consecutive days after HSCT). The survival rate at day 100 post-autologous HSCT was 100%. These data confirm the safety of IV thiotepa plus melphalan HDT prior to autologous HSCT for patients with pediatric CNS/non-CNS solid tumors. Trial registration: JapicCTI-173654.
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Uemura S, Demizu Y, Hasegawa D, Fujikawa T, Inoue S, Nishimura A, Tojyo R, Nakamura S, Kozaki A, Saito A, Kishimoto K, Ishida T, Mori T, Koyama J, Kawamura A, Akasaka Y, Yoshida M, Fukumitsu N, Soejima T, Kosaka Y. The comparison of acute toxicities associated with craniospinal irradiation between photon beam therapy and proton beam therapy in children with brain tumors. Cancer Med 2022; 11:1502-1510. [PMID: 35137555 PMCID: PMC8921900 DOI: 10.1002/cam4.4553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/24/2021] [Accepted: 11/27/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction This study aimed to evaluate acute toxicities associated with irradiation between the X‐CSI (photon beam craniospinal irradiation) and P‐CSI (proton beam craniospinal irradiation) groups in children with brain tumors. Methods Sixty‐two consecutive patients who received initial craniospinal irradiation (CSI) for brain tumors in our center between January 1, 2011 and May 31, 2021, were included in the study. Acute toxicities were retrospectively evaluated during CSI using Common Terminology Criteria for Adverse Events version 5.0. Maximum grades of fatigue, headache, insomnia, nausea, vomiting, dermatitis, constipation, abdominal pain, oropharyngeal mucositis, and hematological toxicities were evaluated. Results Thirty‐six patients received X‐CSI, and 26 patients received P‐CSI. The median dose of CSI was 18.0 Gy in the X‐CSI group and 23.4 Gy (relative biological effectiveness) in the P‐CSI group (p < 0.001). The P‐CSI group had a lower incidence of more than grade 2 nausea (11.5% vs. 69.4%, p = 0.008) and vomiting (7.7% vs. 38.8%, p < 0.001), compared with the X‐CSI group. Multivariate logistic regression analysis with adjustments for potential confounding factors of doses of CSI showed that proton radiation therapy was associated with a marked reduced risk of more than grade 2 nausea and vomiting during CSI (adjusted odds ratio, 0.050; 95% confidential interval, 0.011–0.24; p < 0.001). Conclusion The present study suggests that P‐CSI reduces the acute gastrointestinal toxicities associated with irradiation.
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Affiliation(s)
- Suguru Uemura
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Yusuke Demizu
- Department of Radiation Oncology, Kobe Proton Center, Kobe, Japan
| | - Daiichiro Hasegawa
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Tomoko Fujikawa
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Shotaro Inoue
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Akihiro Nishimura
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Ryunosuke Tojyo
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Sayaka Nakamura
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Aiko Kozaki
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Atsuro Saito
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Kenji Kishimoto
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Toshiaki Ishida
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Takeshi Mori
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Jyunji Koyama
- Department of Neurosurgery, Kobe Children's Hospital, Kobe, Japan
| | | | | | - Makiko Yoshida
- Department of Pathology, Kobe Children's Hospital, Kobe, Japan
| | | | | | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
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Yamazaki F, Yamasaki K, Kiyotani C, Hashii Y, Shioda Y, Hara J, Matsumoto K. Thiotepa-melphalan myeloablative therapy for high-risk neuroblastoma. Pediatr Blood Cancer 2021; 68:e28896. [PMID: 33788375 DOI: 10.1002/pbc.28896] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 12/02/2020] [Accepted: 12/26/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Appropriate high-dose chemotherapy (HDC) for high-risk neuroblastoma has not yet been established. In Japan, a unique HDC regimen that comprises two cycles of a total of 800 mg/m2 of thiotepa and a total of 280 mg/m2 of melphalan is widely utilized. METHODS To evaluate the safety and efficacy of this thiotepa-melphalan high-dose therapy for high-risk neuroblastoma, we reviewed the medical records of 41 patients with high-risk neuroblastoma who underwent this regimen followed by autologous peripheral blood stem cell rescue between 2002 and 2012. MYCN-amplified high-risk neuroblastomas were observed in 23 patients. All patients underwent intensive multidrug induction chemotherapy, but none underwent anti-GD2 antibody immunotherapy. The primary tumor was resected at the adequate time point. RESULTS The median follow-up duration for living patients was 9.2 years (range 5.5-14.0 years). The 5-year event-free survival (EFS) and overall survival from treatment initiation were 41.5 ± 7.7% and 56.1 ± 7.8%, respectively. The 5-year EFS of MYCN-amplified high-risk neuroblastoma patients was 60.9 ± 10.2%, which was significantly superior compared with those with MYCN-nonamplified high-risk neuroblastoma (16.7 ± 8.8%; p < .001). MYCN amplification was the most favorable prognostic factor for EFS (hazard ratio = 0.29; 95% confidence interval = 0.12-0.66). Of the 41 patients, three died because of regimen-related toxicity (infection, n = 2; microangiopathy, n = 1). CONCLUSION The thiotepa-melphalan high-dose therapy with thiotepa and melphalan may be effective for high-risk neuroblastoma. However, this regimen is toxic and warrants special attention in clinical practice.
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Affiliation(s)
- Fumito Yamazaki
- National Center for Child Health and Development, Children's Cancer Center, Tokyo, Japan.,Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kai Yamasaki
- Department of Pediatric Hematology and Oncology, Osaka City General Hospital, Osaka, Japan
| | - Chikako Kiyotani
- National Center for Child Health and Development, Children's Cancer Center, Tokyo, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka University Hospital, Osaka, Japan
| | - Yoko Shioda
- National Center for Child Health and Development, Children's Cancer Center, Tokyo, Japan
| | - Junichi Hara
- Department of Pediatric Hematology and Oncology, Osaka City General Hospital, Osaka, Japan
| | - Kimikazu Matsumoto
- National Center for Child Health and Development, Children's Cancer Center, Tokyo, Japan
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Hiraki T, Fukuoka K, Mori M, Arakawa Y, Matsushita Y, Hibiya Y, Honda S, Kobayashi M, Tanami Y, Ichimura K, Hirato J, Kurihara J, Nakazawa A, Koh K. Application of Genome-Wide DNA Methylation Analysis to Differentiate a Case of Radiation-Induced Glioblastoma From Late-Relapsed Medulloblastoma. J Neuropathol Exp Neurol 2021; 80:552-557. [PMID: 33990838 DOI: 10.1093/jnen/nlab043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Recurrent medulloblastoma can be difficult to diagnose with conventional diagnostic methods because other lesions mimic tumor relapse, particularly at later stages. We report 2 cases of medulloblastoma, both of which seemed to develop late recurrences. Case 1 was a 6-year-old girl who had a medulloblastoma with focal desmoplasia. She was in complete remission for 9 years after treatment but developed an intradural lesion in her thoracic spine, which was pathologically confirmed as tumor recurrence by biopsy. Case 2 was a 10-year-old girl who had a nonmetastatic medulloblastoma. She developed a left cerebellar mass 5 years after the initial diagnosis; the pathological diagnosis was tumor relapse. We performed t-distributed stochastic neighbor embedding of the methylation data from these cases and reference data. In contrast to the consistency of methylation profiling and copy number abnormalities between primary and recurrent tumors of Case 1, the analysis of the recurrent tumor in Case 2 was distinct from medulloblastomas and clustered with "IDH-wild type glioblastomas," suggesting that the recurrent tumor was a radiation-induced glioblastoma. This report highlights the clinical utility of molecular genetic/epigenetic analysis combined with a standard diagnostic approach to confirm the diagnosis of brain tumor recurrence.
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Affiliation(s)
- Takamasa Hiraki
- From Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Kohei Fukuoka
- From Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Makiko Mori
- From Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuki Arakawa
- From Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuko Matsushita
- Division of Brain Tumor Translational Research, National Cancer Center Research Institute, Tokyo, Japan
| | - Yuko Hibiya
- Division of Brain Tumor Translational Research, National Cancer Center Research Institute, Tokyo, Japan
| | - Satoko Honda
- Department of Clinical Research, Saitama Children's Medical Center, Saitama, Japan
| | - Masao Kobayashi
- Department of Radiology (MK, YT), Saitama Children's Medical Center, Saitama, Japan.,Department of Radiology, Jikei University School of Medicine, Tokyo, Japan
| | - Yutaka Tanami
- Department of Radiology (MK, YT), Saitama Children's Medical Center, Saitama, Japan
| | - Koichi Ichimura
- Division of Brain Tumor Translational Research, National Cancer Center Research Institute, Tokyo, Japan
| | - Junko Hirato
- Department of Pathology, Public Tomioka General Hospital, Gunma, Japan
| | - Jun Kurihara
- Department of Neurosurgery, Saitama Children's Medical Center, Saitama, Japan
| | - Atsuko Nakazawa
- Department of Clinical Research, Saitama Children's Medical Center, Saitama, Japan
| | - Katsuyoshi Koh
- From Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
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Major A, Cox SM, Volchenboum SL. Using big data in pediatric oncology: Current applications and future directions. Semin Oncol 2020; 47:56-64. [DOI: 10.1053/j.seminoncol.2020.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 12/13/2022]
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