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Bouwman FCM, Verhoeven BH, Klein WM, Schultze Kool LJ, de Blaauw I. Congenital Vascular Malformations in Children: From Historical Perspective to a Multidisciplinary Approach in the Modern Era-A Comprehensive Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:567. [PMID: 38790562 PMCID: PMC11119901 DOI: 10.3390/children11050567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024]
Abstract
Congenital vascular malformations (CVMs) are the result of an aberrant development during embryogenesis. Although these lesions are present at birth, they are not always visible yet. Once symptomatic, patients suffer from pain, bleeding, ulcers, infections or lymphatic leakage, depending on the subtype of vessels involved. Treatment includes conservative management, surgery, sclerotherapy, embolization and pharmacological therapy. The clinical presentation varies widely and treatment can be challenging due to the rarity of the disease and potential difficulties of treatment. This review gives an overview of the historical developments in diagnosis and classification and exposes the key elements of innovations in the past decades on the identification of genetic mutations and personalized treatment. These advances in the field and a multidisciplinary approach are highly valuable in the optimization of clinical care aimed at both curing or stabilizing the CVM and pursuing physical and psychosocial wellbeing.
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Affiliation(s)
- Frédérique C. M. Bouwman
- Department of Pediatric Surgery, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (F.C.M.B.); (B.H.V.)
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.M.K.); (L.J.S.K.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Bas H. Verhoeven
- Department of Pediatric Surgery, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (F.C.M.B.); (B.H.V.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Willemijn M. Klein
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.M.K.); (L.J.S.K.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Leo J. Schultze Kool
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.M.K.); (L.J.S.K.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Ivo de Blaauw
- Department of Pediatric Surgery, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (F.C.M.B.); (B.H.V.)
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Kamhieh Y, Mitra R, Burnett T, Jones H, Roblin G, Hall A. Sirolimus for Pediatric Cervicofacial Lymphatic Malformation: A Systematic Review and Meta-Analysis. Laryngoscope 2024; 134:2038-2047. [PMID: 37812168 DOI: 10.1002/lary.31091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE This study is a systematic review and meta-analysis of the efficacy and safety of sirolimus in the management of pediatric cervicofacial lymphatic malformations (LMs). DATA SOURCES EMBASE, Medline, Scopus, and Cochrane databases were searched, along with the reference list of all included articles. REVIEW METHODS The study protocol was registered with PROSPERO and a systematic literature search strategy was designed and conducted with the aid of a medical librarian. All studies including case reports were included, with pooled analysis of raw data. A meta-analysis was conducted of magnetic resonance imaging (MRI), clinical, and airway outcomes. RESULTS Thirteen case series and five individual case reports were included. Meta-analysis showed 78% (95% CI 57%-94%) of 62 patients had a reduction in LM volume, on MRI criteria, by 20% or more, and 32% (95% CI 11%-57%) had a reduction of 50% or more. Further meta-analysis showed 97% (95% CI 88%-100%) of 78 patients reported some clinical improvement on sirolimus. Sirolimus may be of particular value in management of airway LMs; out of 27 tracheostomy-dependent patients, meta-analysis showed 33% (95% CI 1%-78%) were decannulated after starting sirolimus. Individual patient meta-analysis on 24 individuals showed a statistically significant better response to sirolimus when initiated under the age of 2 years. CONCLUSION This review and meta-analysis support the efficacy of sirolimus in pediatric LMs of the head, neck, and airway. A large multi-center trial is needed to further explore its role and limitations. Laryngoscope, 134:2038-2047, 2024.
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Affiliation(s)
| | - Robin Mitra
- Department of Statistics, University College of London, London, UK
| | - Thomas Burnett
- Department of Mathematical Sciences, University of Bath, Bath, BA2 7AY, UK
| | - Hugh Jones
- Cardiff University, Cardiff, CF10 3AT, UK
| | - Graham Roblin
- ENT Department Noah's Ark Children's Hospital, Cardiff, UK
| | - Andrew Hall
- ENT Department Noah's Ark Children's Hospital, Cardiff, UK
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3
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Qaderi S, Javinani A, Blumenfeld YJ, Krispin E, Papanna R, Chervenak FA, Shamshirsaz AA. Mammalian target of rapamycin inhibitors: A new-possible approach for in-utero medication therapy. Prenat Diagn 2024; 44:88-98. [PMID: 38177082 DOI: 10.1002/pd.6492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
The mammalian/mechanistic target of rapamycin (mTOR) is a protein kinase that plays a crucial role in regulating cellular growth, metabolism, and survival. Although there is no absolute contraindication for the use of mTOR inhibitors during pregnancy, the specific fetal effects remain unknown. Available data from the past 2 decades have examined the use of mTOR inhibitors during pregnancy in patients with solid organ transplantation, showing no clear link to fetal complications or structural abnormalities. Recently, a handful of case reports and series have described transplacental therapy of mTOR inhibitors to control symptomatic and complicated pathologies in the fetus. The effect of these agents includes a significant reduction in lesion size in the fetus and a reduced need for mechanical ventilation in neonates. In this context, we delve into the potential of mTOR inhibitors as in-utero therapy for fetal abnormalities, with a primary focus on lymphatic malformation (LM) and cardiac rhabdomyoma (CR). While preliminary reports underscore the efficacy of mTOR inhibitors for the treatment of fetal CR and fetal brain lesions associated with tuberous sclerosis complex, chylothorax, and LMs, additional investigation and clinical trials are essential to comprehensively assess the safety and efficacy of these medications.
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Affiliation(s)
- Shohra Qaderi
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Javinani
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Eyal Krispin
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ramesha Papanna
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UT Health Houston, Houston, Texas, USA
| | - Frank A Chervenak
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, New York, USA
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zeng Z, Liao H, Hu F, Zhao F, Liu H, Hu Q, Yu H. Outcome of Sclerotherapy in a Preterm Infant with a Giant Fetal Neck Lymphatic Malformation: A Case Report. Int J Womens Health 2023; 15:1771-1778. [PMID: 38020936 PMCID: PMC10656836 DOI: 10.2147/ijwh.s430858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Lymphatic malformation (LM), most commonly present in the neck area, is benign vascular malformations of the lymphatic system. In an infant, however, LM poses a high risk of adverse outcomes. Case Presentation We present a case with a giant fetal LM. Through ultrasonography, at 23+ weeks of gestation, a septate cystic mass 7.2×6.5×6.3 cm in size was found on the right side of the fetus's neck. After extensive counseling by the multidisciplinary team, the parents chose to continue the pregnancy. Severe fetal tracheal compression was observed at 29 weeks by magnetic resonance imaging (MRI). At 31 weeks and 5 days, owing to suspected fetal distress, an emergency cesarean section was performed and a male baby weighing 1720 g was delivered. The mass was 10×16×8 cm in size and ex utero intrapartum treatment (EXIT) was implemented. Due to progressive growth of the mass secondary to intralesional bleeding, an intralesional injection of bleomycin was administered three days later. This injection was repeated at the age of 1 month and 8 days. The baby was followed up and, by a year after his birth, LM had disappeared. The baby has since been in good health. Conclusion Accurate prenatal diagnosis and regular monitoring of a fetus with LM may improve prognosis. It is essential to have a trained multidisciplinary team to evaluate the condition of the fetus and the neonate and to provide treatment based on the evaluation. Our experience with intralesional bleomycin injection for the treatment of a giant fetal neck LM in a preterm infant had a favorable outcome. Long-term follow-up by a multidisciplinary team is needed in such cases.
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Affiliation(s)
- Zhaomin Zeng
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
| | - Hua Liao
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
| | - Fan Hu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Fumin Zhao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Hongyan Liu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
| | - Qing Hu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
| | - Haiyan Yu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
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Saibene AM, Rosso C, Felisati G, Pignataro L, Schindler A, Ghilardi G, Colletti G, Gaffuri M, Mozzanica F. Sirolimus treatment for paediatric head and neck lymphatic malformations: a systematic review. Eur Arch Otorhinolaryngol 2023; 280:3529-3540. [PMID: 37115326 PMCID: PMC10313583 DOI: 10.1007/s00405-023-07991-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE This PRISMA-compliant systematic review aimed to assess risks and benefits of sirolimus treatment for paediatric lymphatic malformations by focusing not only on treatment efficacy but also on possible treatment-related adverse events, and treatment combinations with other techniques. METHODS Search criteria were applied to MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, and ClinicalTrials.gov databases and included all studies published up to March 2022 reporting paediatric lymphatic malformations treated with sirolimus. We selected all original studies that included treatment outcomes. After the removal of duplicates, selection of abstracts and full-text articles, and quality assessment, we reviewed eligible articles for patient demographics, lymphatic malformation type, size or stage, site, clinical response rates, sirolimus administration route and dose, related adverse events, follow-up time, and concurrent treatments. RESULTS Among 153 unique citations, 19 studies were considered eligible, with reported treatment data for 97 paediatric patients. Most studies (n = 9) were case reports. Clinical response was described for 89 patients, in whom 94 mild-to-moderate adverse events were reported. The most frequently administered treatment regimen was oral sirolimus 0.8 mg/m2 twice a day, with the aim of achieving a blood concentration of 10-15 ng/mL. CONCLUSION Despite promising results for sirolimus treatment in lymphatic malformation, the efficacy and safety profile of remains unclear due to the lack of high-quality studies. Systematic reporting of known side effects, especially in younger children, should assist clinicians in minimising treatment-associated risks. At the same time, we advocate for prospective multicentre studies with minimum reporting standards to facilitate improved candidate selection.
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Affiliation(s)
- Alberto Maria Saibene
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via Antonio di Rudinì, 8, 20142, Milan, Italy.
| | - Cecilia Rosso
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via Antonio di Rudinì, 8, 20142, Milan, Italy
| | - Giovanni Felisati
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via Antonio di Rudinì, 8, 20142, Milan, Italy
| | - Lorenzo Pignataro
- Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, Milan, Italy
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Giorgio Ghilardi
- Clinica Chirurgica Generale, Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Giacomo Colletti
- Cranio Maxillo Facial Surgery, Università Degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Michele Gaffuri
- Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, Milan, Italy
| | - Francesco Mozzanica
- Department of Clinical Sciences and Community Health, San Giuseppe Hospital, Università Degli Studi di Milano, Milan, Italy
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Leboulanger N, Bisdorff A, Boccara O, Dompmartin A, Guibaud L, Labreze C, Lagier J, Lebrun-Vignes B, Herbreteau D, Joly A, Malloizel-Delaunay J, Martel A, Munck S, Saint-Aubin F, Maruani A. French national diagnosis and care protocol (PNDS, protocole national de diagnostic et de soins): cystic lymphatic malformations. Orphanet J Rare Dis 2023; 18:10. [PMID: 36639640 PMCID: PMC9837920 DOI: 10.1186/s13023-022-02608-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 12/29/2022] [Indexed: 01/15/2023] Open
Abstract
Cystic lymphatic malformations (LMs) are rare chronic conditions which management differs according to the type (macrocystic LMs, microcystic LMs or both). Studies are lacking due to rarity of the pathology. We aimed to establish a French National Diagnosis and Care Protocol (PNDS: Protocole National de Diagnostic et de Soins), to provide health professionals with free open access synthesis on optimal management and care of patients with LMs ( https://www.has-sante.fr/upload/docs/application/pdf/2021-03/malformations_lymphatiques_kystiques_-_pnds.pdf ). The process included a critical review of the literature and multidisciplinary expert consensus. LMs are congenital but are not always discovered at birth. Nearly 75% of them are located in the head and neck because of the highly dense lymphatic system in this region. Physical examination (showing painless masses with normal skin color and depressible consistency, or cutaneous/mucosal lymphangiectasia) and color Doppler ultrasonography, usually allow for diagnosis. MRI (involving T2 sequences with fat saturation in at least two spatial planes) is the tool of choice for evaluating anatomical extension, characterizing lesions (microcystic and macrocystic), and before considering therapeutic management. A biopsy, coupled to a blood sample, can also be used for molecular biology analyses, to search for activating mutations of the PIK3CA gene, particularly with LM integrating in a syndromic form (CLOVES or Klippel-Trenaunay syndrome) but also in certain isolated (or common) LMs. The spontaneous evolution of LMs, in particular microcystic forms, is often toward progressive aggravation, with an increase in the number of vesicles, thickening, increased oozing and bleeding, while pure macrocystic LMs may regress due to "natural sclerosis", i.e. fibrosis secondary to an inflammatory reorganization after common infantile infections. In case of voluminous LMs or syndromic forms, functional and psychological repercussions can be major, deteriorating the patient's quality of life. LMs must be treated by physicians integrated in multidisciplinary teams, and be personalized. Management is a life-long process that involves one or several of these therapies: conservative management, physical therapy (compression), sclerotherapy, surgery, drugs such as mTOR inhibitors (sirolimus), that has shown efficacy in decreasing the volume of LMs, and, more recently, PI3K-inhibitors in syndromic forms. Psychological and social support is necessary, taking into account the patient and his family.
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Affiliation(s)
- Nicolas Leboulanger
- Otolaryngology - Head and Neck Surgery Department. National Reference Center for Rare Otolaryngological Malformations (MALO), Necker Enfants Malades Hospital, 149 Rue de Sèvres, 75015, Paris, France. .,INSERM U955, Paris Cité University. ERN Cranio, Paris, France.
| | - Annouk Bisdorff
- grid.411296.90000 0000 9725 279XDepartment of Interventional Radiology, Lariboisière Hospital, Paris, France
| | - Olivia Boccara
- grid.412134.10000 0004 0593 9113Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), Necker Enfants Malades Hospital, Paris, France
| | - Anne Dompmartin
- grid.411149.80000 0004 0472 0160Department of Dermatology, CHU Côte de Nacre, Caen, France
| | - Laurent Guibaud
- grid.413852.90000 0001 2163 3825Department of Radiology, Hôpital Mère-Enfant, CHU de Lyon, Lyon, France
| | - Christine Labreze
- grid.42399.350000 0004 0593 7118Department of Dermatology, Pellegrin Hospital, CHU de Bordeaux, Bordeaux, France
| | - Jacques Lagier
- grid.410528.a0000 0001 2322 4179Department of Ophthalmology, CHU de Nice, Nice, France
| | - Bénédicte Lebrun-Vignes
- grid.411439.a0000 0001 2150 9058Pharmacovigilance Unit, AP-HP, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - Denis Herbreteau
- grid.411167.40000 0004 1765 1600Department of Neuroradiology and Interventional Radiology - Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU de Tours, Tours, France
| | - Aline Joly
- grid.411167.40000 0004 1765 1600Department of Maxillofacial Surgery - Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU de Tours, 37044 Tours, Cedex 9 France
| | - Julie Malloizel-Delaunay
- grid.411175.70000 0001 1457 2980Department of Vascular Medicine, Rangueil Hospital, CHU de Toulouse, Toulouse, France
| | - Arnaud Martel
- grid.410528.a0000 0001 2322 4179Department of Ophthalmology, CHU de Nice, Nice, France
| | - Stéphane Munck
- grid.460782.f0000 0004 4910 6551Département d’enseignement et de Recherche en Médecine Générale, Retines, Healthy, Université Côte d’Azur, 06000 Nice, France
| | | | - Annabel Maruani
- grid.411167.40000 0004 1765 1600Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU de Tours, Tours, France ,grid.12366.300000 0001 2182 6141INSERM 1246 ‑ SPHERE, Universities of Tours and Nantes, 37000 Tours, France
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Cohen-Cutler S, Szymanski LJ, Bockoven C, Miller JM, Moke D, Anselmo DM, Lee J, Luu M. Catastrophic congenital hemangioma with severe coagulopathy leading to fatal cardiac failure: Case report and review. Pediatr Dermatol 2021; 38:1276-1282. [PMID: 34595775 DOI: 10.1111/pde.14825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We present a complex case of a neonate, delivered urgently for hydrops fetalis, with a large vascular mass of the extremity, diagnosed postnatally as a congenital hemangioma. The patient suffered immediate cardiac compromise and severe coagulopathy atypical for the diagnosis and subsequently died from these complications. Treatment was imperative but challenging due to a lack of a standardized treatment approach and few historical reports of equally critically ill patients. In this report, we review potential medical and surgical interventions and discuss treatment considerations in similar, life-threatening cases of congenital hemangiomas.
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Affiliation(s)
- Sally Cohen-Cutler
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Linda J Szymanski
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Anatomic Pathology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Crystal Bockoven
- Department of Anatomic Pathology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Joseph M Miller
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Diana Moke
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dean M Anselmo
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jessica Lee
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Pediatric Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Minnelly Luu
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Dermatology, Children's Hospital Los Angeles, Los Angeles, CA, USA
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