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Timmermann B, Alapetite C, Dieckmann K, Kortmann RD, Lassen-Ramshad Y, Maduro JH, Ramos Albiac M, Ricardi U, Weber DC. ESTRO-SIOPE guideline: Clinical management of radiotherapy in atypical teratoid/rhabdoid tumors (AT/RTs). Radiother Oncol 2024; 196:110227. [PMID: 38492671 DOI: 10.1016/j.radonc.2024.110227] [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: 03/08/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND AND PURPOSE Treatment of patients with atypical teratoid/rhabdoid (AT/RT) is challenging, especially when very young (below the age of three years). Radiotherapy (RT) is part of a complex trimodality therapy. The purpose of this guideline is to provide appropriate recommendations for RT in the clinical management of patients not enrolled in clinical trials. MATERIALS AND METHODS Nine European experts were nominated to form a European Society for Radiotherapy and Oncology (ESTRO) guideline committee. A systematic literature search was conducted in PubMed/MEDLINE and Web of Science. They discussed and analyzed the evidence concerning the role of RT in the clinical management of AT/RT. RESULTS Recommendations on diagnostic imaging, therapeutic principles, RT considerations regarding timing, dose, techniques, target volume definitions, dose constraints of radiation-sensitive organs at risk, concomitant chemotherapy, and follow-up were considered. Treating children with AT/RT within the framework of prospective trials or prospective registries is of utmost importance. CONCLUSION The present guideline summarizes the evidence and clinical-based recommendations for RT in patients with AT/RT. Prospective clinical trials and international, large registries evaluating modern treatment approaches will contribute to a better understanding of the best treatment for these children in future.
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Affiliation(s)
- Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Germany, German Cancer Consortium (DKTK), Germany.
| | - Claire Alapetite
- Department of Radiation Oncology and Proton Therapy Center, Institut Curie, Paris-Orsay, France
| | - Karin Dieckmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Rolf-Dieter Kortmann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Germany, German Cancer Consortium (DKTK), Germany; University of Leipzig Medical Center, Leipzig, Germany
| | | | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | | | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen-PSI, Switzerland; Department of Radiation Oncology. Inselspital, Bern University Hospital, University of Bern, Switzerland
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Calandrelli R, Massimi L, Pilato F, Verdolotti T, Ruggiero A, Attinà G, Gessi M, Colosimo C. Atypical Teratoid Rhabdoid Tumor: Proposal of a Diagnostic Pathway Based on Clinical Features and Neuroimaging Findings. Diagnostics (Basel) 2023; 13:diagnostics13030475. [PMID: 36766580 PMCID: PMC9914341 DOI: 10.3390/diagnostics13030475] [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: 12/31/2022] [Revised: 01/17/2023] [Accepted: 01/26/2023] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To assess the main imaging and clinical features in adult- and pediatric-onset atypical teratoid rhabdoid tumor (ATRT) in order to build a predefined pathway useful for the diagnosis. METHODS We enrolled 11 ATRT patients (10 children, one adult) and we conducted a literature search on PubMed Central using the key terms "adult" or "pediatric" and "atypical teratoid/rhabdoid tumor". We collected clinical and neuroradiological data reported in previous studies and combined them with those from our case series. A three step process was built to reach diagnosis by identifying the main distinctive clinical and imaging features. RESULTS Clinical evaluation: neurological symptoms were nonspecific. ATRT was more frequent in children under 3 years of age (7 out of 10 children) and infratentorial localization was reported more frequently in children under the age of 24 months. Midline/off-midline localization was influenced by the age. IMAGING FINDINGS Preferential location near the ventricles and liquor spaces and the presence of eccentric cysts were hallmark for ATRT; higher frequency of peripheral cysts was detected in children and in the supratentorial compartment (five out of eight patients with solid-cystic ATRT). Leptomeningeal dissemination at diagnosis was common (5 out of 10 children), while intratumoral hemorrhage, calcifications, and high cellularity were non-specific findings. Histopathological analysis: specific immunohistochemical markers were essential to confirm the diagnosis. CONCLUSION In younger children, a bulky, heterogeneous mass with eccentric cystic components and development near ventricles or cisternal spaces may be suggestive of ATRT. ATRT diagnosis is more challenging in adults and relies exclusively on neuropathological examination.
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Affiliation(s)
- Rosalinda Calandrelli
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, 00168 Rome, Italy
- Correspondence:
| | - Luca Massimi
- Pediatric Neurosurgery, Neurosurgery Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, 00168 Rome, Italy
| | - Fabio Pilato
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Tommaso Verdolotti
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, 00168 Rome, Italy
| | - Antonio Ruggiero
- UOSD di Oncologia Pediatrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Largo F.sco Vito 1, 00168 Rome, Italy
| | - Giorgio Attinà
- UOSD di Oncologia Pediatrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Marco Gessi
- Neuropathology Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Cesare Colosimo
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, 00168 Rome, Italy
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Liu YL, Tsai ML, Chen CI, Yar N, Tsai CW, Lee HL, Kuo CC, Ho WL, Hsieh KLC, Tseng SH, Miser JS, Chang CY, Chang H, Huang WC, Wong TT, Wu ATH, Yen YC. Atypical Teratoid/Rhabdoid Tumor in Taiwan: A Nationwide, Population-Based Study. Cancers (Basel) 2022; 14:cancers14030668. [PMID: 35158938 PMCID: PMC8833760 DOI: 10.3390/cancers14030668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Atypical teratoid/rhabdoid tumor (AT/RT) is a rare, highly malignant CNS neoplasm with poor prognosis. A retrospective population-based analysis of patients with the diagnosis of AT/RT, registered between 1999 and 2014 in Taiwan, showed that: (1) AT/RT had a higher prevalence in males, in children < 36 months of age, and at infratentorial sites; (2) older age (≥12 months), presence of the tumor in the supratentorial region, use of radiotherapy, chemotherapy, or both were associated with better prognosis compared to surgery or no treatment. These data represent a historical experience with AT/RT in Taiwan and may inform risk stratification and clinical trial design. Abstract Background: Atypical teratoid/rhabdoid tumor (AT/RT) is a rare, highly aggressive embryonal brain tumor most commonly presenting in young children. Methods: We performed a nationwide, population-based study of AT/RT (ICD-O-3 code: 9508/3) in Taiwan using the Taiwan Cancer Registry Database and the National Death Certificate Database. Results: A total of 47 cases (male/female = 29:18; median age at diagnosis, 23.3 months (IQR: 12.5–87.9)) were diagnosed with AT/RT between 1999 and 2014. AT/RT had higher prevalence in males (61.70%), in children < 36 months (55.32%), and at infratentorial or spinal locations (46.81%). Survival analyses demonstrated that patients ≥ 3 years of age (n = 21 (45%)) had a 5y-OS of 41% (p < 0.0001), treatment with radiotherapy only (n = 5 (11%)) led to a 5y-OS of 60%, treatment with chemotherapy with or without radiotherapy (n = 27 (62%)) was associated with a 5y-OS of 45% (p < 0.0001), and patients with a supratentorial tumor (n = 11 (23%)) had a 5y-OS of 51.95%. Predictors of better survival on univariate Cox proportional hazard modeling and confirmed with multivariate analysis included older age (≥1 year), supratentorial sites, and the administration of radiotherapy, chemotherapy, or both. Gender had no effect on survival. Conclusion: Older age, supratentorial site, and treatment with radiotherapy, chemotherapy, or both significantly improves the survival of patients with AT/RT.
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Affiliation(s)
- Yen-Lin Liu
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan; (Y.-L.L.); (M.-L.T.); (W.-L.H.); (C.-Y.C.); (H.C.)
- Department of Pediatrics, Taipei Medical University Hospital, Taipei 110, Taiwan
- Pediatric Brain Tumor Program, Taipei Cancer Center, Taipei Neurological Institute, Taipei Medical University, Taipei 110, Taiwan; (H.-L.L.); (K.L.-C.H.); (J.S.M.); (T.-T.W.)
- TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Min-Lan Tsai
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan; (Y.-L.L.); (M.-L.T.); (W.-L.H.); (C.-Y.C.); (H.C.)
- Department of Pediatrics, Taipei Medical University Hospital, Taipei 110, Taiwan
- Pediatric Brain Tumor Program, Taipei Cancer Center, Taipei Neurological Institute, Taipei Medical University, Taipei 110, Taiwan; (H.-L.L.); (K.L.-C.H.); (J.S.M.); (T.-T.W.)
| | - Chang-I Chen
- Department of Health Care Administration, College of Management, Taipei Medical University, Taipei 110, Taiwan; (C.-I.C.); (N.Y.); (C.-C.K.)
| | - Noi Yar
- Department of Health Care Administration, College of Management, Taipei Medical University, Taipei 110, Taiwan; (C.-I.C.); (N.Y.); (C.-C.K.)
| | - Ching-Wen Tsai
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei 110, Taiwan;
| | - Hsin-Lun Lee
- Pediatric Brain Tumor Program, Taipei Cancer Center, Taipei Neurological Institute, Taipei Medical University, Taipei 110, Taiwan; (H.-L.L.); (K.L.-C.H.); (J.S.M.); (T.-T.W.)
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei 110, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Chia-Chun Kuo
- Department of Health Care Administration, College of Management, Taipei Medical University, Taipei 110, Taiwan; (C.-I.C.); (N.Y.); (C.-C.K.)
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei 110, Taiwan
- Ph.D. Program for Cancer Molecular Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University and Academia Sinica, Taipei 110, Taiwan
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan
| | - Wan-Ling Ho
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan; (Y.-L.L.); (M.-L.T.); (W.-L.H.); (C.-Y.C.); (H.C.)
- Department of Pediatrics, Taipei Medical University Hospital, Taipei 110, Taiwan
- Pediatric Brain Tumor Program, Taipei Cancer Center, Taipei Neurological Institute, Taipei Medical University, Taipei 110, Taiwan; (H.-L.L.); (K.L.-C.H.); (J.S.M.); (T.-T.W.)
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Kevin Li-Chun Hsieh
- Pediatric Brain Tumor Program, Taipei Cancer Center, Taipei Neurological Institute, Taipei Medical University, Taipei 110, Taiwan; (H.-L.L.); (K.L.-C.H.); (J.S.M.); (T.-T.W.)
- TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei 110, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei 110, Taiwan
| | - Sung-Hui Tseng
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei 110, Taiwan;
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - James S. Miser
- Pediatric Brain Tumor Program, Taipei Cancer Center, Taipei Neurological Institute, Taipei Medical University, Taipei 110, Taiwan; (H.-L.L.); (K.L.-C.H.); (J.S.M.); (T.-T.W.)
- Department of Pediatrics, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
- Cancer Center, Taipei Medical University Hospital, Taipei 110, Taiwan
| | - Chia-Yau Chang
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan; (Y.-L.L.); (M.-L.T.); (W.-L.H.); (C.-Y.C.); (H.C.)
- Department of Pediatrics, Taipei Medical University Hospital, Taipei 110, Taiwan
- Pediatric Brain Tumor Program, Taipei Cancer Center, Taipei Neurological Institute, Taipei Medical University, Taipei 110, Taiwan; (H.-L.L.); (K.L.-C.H.); (J.S.M.); (T.-T.W.)
| | - Hsi Chang
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan; (Y.-L.L.); (M.-L.T.); (W.-L.H.); (C.-Y.C.); (H.C.)
- Department of Pediatrics, Taipei Medical University Hospital, Taipei 110, Taiwan
| | - Wen-Chang Huang
- Department of Pathology, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan;
| | - Tai-Tong Wong
- Pediatric Brain Tumor Program, Taipei Cancer Center, Taipei Neurological Institute, Taipei Medical University, Taipei 110, Taiwan; (H.-L.L.); (K.L.-C.H.); (J.S.M.); (T.-T.W.)
- TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei 110, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Neuroscience Research Center, Taipei Medical University Hospital, Taipei 110, Taiwan
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Taipei Medical University Hospital, Taipei Neuroscience Institute, Taipei Medical University, Taipei 110, Taiwan
| | - Alexander T. H. Wu
- TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei 110, Taiwan
- The Ph.D. Program of Translational Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan
- Clinical Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei 110, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 114, Taiwan
- Correspondence: (A.T.H.W.); (Y.-C.Y.)
| | - Yu-Chun Yen
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei 110, Taiwan;
- Correspondence: (A.T.H.W.); (Y.-C.Y.)
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Fuchs J, Murtha-Lemekhova A, Kessler M, Ruping F, Günther P, Fichtner A, Sturm D, Hoffmann K. A Systematic Review and Meta-Analysis of Malignant Rhabdoid and Small Cell Undifferentiated Liver Tumors: A Rational for a Uniform Classification. Cancers (Basel) 2022; 14:cancers14020272. [PMID: 35053437 PMCID: PMC8774069 DOI: 10.3390/cancers14020272] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Malignant rhabdoid tumors of the liver are very rare pediatric liver tumors with a devastating prognosis. It is currently unclear which histological subtypes of pediatric liver tumors belong to this entity and how these tumors should be treated. In this systematic review with meta-analysis, we analyzed all reports on pediatric patients with malignant rhabdoid liver tumors, but also with so-called small cell undifferentiated liver tumors. This is another rare liver tumor subtype that has recently been regarded to belong to the entity of rhabdoid tumors by some authors. The main result of this study is that these two tumor subtypes show large overlap on several levels and even mixtures of both histological patterns have been documented. Our meta-analysis provides an evidence base for the recommendation to classify these two tumor subtypes as one entity. We showed that treatment of these tumors with hepatoblastoma directed chemotherapy is ineffective and that a therapy with chemotherapy regimens initially applied for soft tissue sarcoma is associated with a significantly better survival. This study represents the highest level of evidence available for these rare liver tumors. Abstract Background: Rhabdoid liver tumors in children are rare and have a devastating prognosis. Reliable diagnosis and targeted treatment approaches are urgently needed. Immunohistochemical and genetic studies suggest that tumors formerly classified as small cell undifferentiated hepatoblastoma (SCUD) belong to the entity of malignant rhabdoid tumors of the liver (MRTL), in contrast to hepatoblastomas with focal small cell histology (F-SCHB). This may have relevant implications on therapeutic approaches. However, studies with larger cohorts investigating the clinical relevance of the histological and genetic similarities for patients are lacking. Purpose: To analyze possible similarities and differences in patient characteristics, tumor biology, response to treatment, and clinical course of patients with MRTL, SCUD and F-SCHB. Applied therapeutic regimens and prognostic factors are investigated. Methods: A systematic literature search of MEDLINE, Web of Science, and CENTRAL was performed for this PRISMA-compliant systematic review. All studies of patients with MRTL, SCUD and F-SCHB that provided individual patient data were included. Demographic, histological, and clinical characteristics of the three subgroups were compared. Overall survival (OS) was estimated with the Kaplan–Meier method and prognostic factors investigated in a multivariable Cox regression model. Protocol registered: PROSPERO 2021 CRD42021258760. Results: Fifty-six studies with a total of 118 patients were included. The two subgroups MRTL and SCUD did not differ significantly in baseline patient characteristics. However, heterogenous diagnostic and therapeutic algorithms were applied. Large histological and clinical overlap between SCUD and MRTL could be shown. Two-year OS was 22% for MRTL and 13% for SCUD, while it was significantly better in F-SCHD (86%). Chemotherapeutic regimens for hepatoblastoma proved to be ineffective for both SCUD and MRTL, but successful in F-SCHB. Soft tissue sarcoma chemotherapy was associated with significantly better survival for MRTL and SCUD, but was rarely applied in SCUD. Patients who did not undergo surgical tumor resection had a significantly higher risk of death. Conclusions: While F-SCHB is a subtype of HB, SCUD should be classified and treated as a type of MRTL. Surgical tumor resection in combination with intensive, multi-agent chemotherapy is the only chance for cure of these tumors. Targeted therapies are highly needed to improve prognosis. Currently, aggressive regimens including soft tissue sarcoma chemotherapy, extensive resection, radiotherapy or even liver transplantation are the only option for affected children.
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany; (J.F.); (A.M.-L.)
- Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.K.); (P.G.); (A.F.)
| | - Anastasia Murtha-Lemekhova
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany; (J.F.); (A.M.-L.)
- Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.K.); (P.G.); (A.F.)
| | - Markus Kessler
- Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.K.); (P.G.); (A.F.)
- Department of General, Visceral and Transplantation Surgery, Division of Pediatric Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Fabian Ruping
- Department of General, Visceral and Transplantation Surgery, Division of Pediatric Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Patrick Günther
- Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.K.); (P.G.); (A.F.)
- Department of General, Visceral and Transplantation Surgery, Division of Pediatric Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Alexander Fichtner
- Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.K.); (P.G.); (A.F.)
- Department of Pediatrics I, Division of Pediatric Gastroenterology, University Children’s Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Dominik Sturm
- Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- Hopp Children’s Cancer Center (KiTZ), 69120 Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany; (J.F.); (A.M.-L.)
- Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.K.); (P.G.); (A.F.)
- Correspondence: ; Tel.: +49-6221-566110; Fax: +49-6221-564215
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