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Merkx R, Leerink JM, Feijen E(LA, de Baat EC, Bellersen L, Bresters D, van Dalen EC, van Dulmen-den Broeder E, van der Heiden-van der Loo M, van den Heuvel-Eibrink MM, Kok JL, Louwerens M, Maas AH, Neggers SJ, Ronckers CM, Teepen JC, Teske AJ, Tissing WJ, de Vries AC, Weijers G, de Korte CL, Loonen J, Mavinkurve-Groothuis AM, van der Pal HJ, Kremer LC, Kok WE, Kapusta L. Extensive Cardiac Function Analyses Using Contemporary Echocardiography in Childhood Cancer Survivors: A DCCSS LATER Study. JACC CardioOncol 2023; 5:472-485. [PMID: 37614574 PMCID: PMC10443197 DOI: 10.1016/j.jaccao.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 08/25/2023] Open
Abstract
Background Childhood cancer survivors (CCS) are at risk for cardiotoxicity. Objectives We sought to assess how cardiac dysfunction measurements in CCS overlap and are differentially influenced by risk factors. Methods This cross-sectional Dutch Childhood Cancer Survivor Study evaluated echocardiograms of 1,397 ≥5-year CCS and 277 siblings. Of CCS, n = 1,254 received cardiotoxic (anthracyclines/mitoxantrone/radiotherapy involving the heart region [RTheart]) and n = 143 received potentially cardiotoxic (cyclophosphamide, ifosfamide, or vincristine) therapy. We assessed demographic, treatment-related, and traditional cardiovascular risk factors for cardiac dysfunction using multivariable logistic regression. Results CCS were a median of 26.7 years after diagnosis; 49% were women. Abnormal left ventricular ejection fraction (LVEF) (defined as <52% in men, <54% in women) occurred most commonly in CCS treated with anthracyclines and RTheart combined (38%). Age/sex-specific abnormal global longitudinal strain (GLS) occurred most commonly in CCS treated with RTheart, either with (41%) or without (38%) anthracyclines. Of CCS with normal LVEF, 20.2% showed abnormal GLS. Diastolic dysfunction grade ≥II was rare. Abnormal LVEF was mainly associated with female sex, anthracycline dose, and only in women, RTheart dose. Abnormal GLS was associated with female sex, RTheart dose, diastolic blood pressure, and only in women, anthracycline dose. Cyclophosphamide, ifosfamide, and vincristine were not associated with LVEF or GLS. Compared with siblings, CCS showed higher risk of abnormal LVEF (OR: 2.9; 95% CI: 1.4-6.6) and GLS (OR: 2.1; 95% CI: 1.2-3.7), independent of (potentially) cardiotoxic treatment-related and cardiovascular risk factors. Conclusions Abnormal LVEF and GLS constitute complementary measures of systolic dysfunction among long-term CCS. Their diagnostic value may differ according to cardiotoxic exposures. Also, CCS have residual, unexplained risk of cardiac dysfunction. (Early Detection of Cardiac Dysfunction in Childhood Cancer Survivors, a DCOG LATER study; NTR7481).
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Affiliation(s)
- Remy Merkx
- Medical Imaging/Radiology, Medical UltraSound Imaging Centre, Radboud Institute for Health Sciences, Radboud university medical center, the Netherlands
| | - Jan M. Leerink
- Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Esmée C. de Baat
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Louise Bellersen
- Cardiology, Radboud university medical center, Nijmegen, the Netherlands
| | - Dorine Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | | | | | - Marry M. van den Heuvel-Eibrink
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Pediatric Oncology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, the Netherlands
- Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Judith L. Kok
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Marloes Louwerens
- Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Angela H.E.M. Maas
- Cardiology, Radboud university medical center, Nijmegen, the Netherlands
| | | | - Cécile M. Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Childhood Cancer Epidemiology/German Childhood Cancer Registry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jop C. Teepen
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Arco J. Teske
- Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Wim J.E. Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Andrica C.H. de Vries
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Pediatric Oncology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Gert Weijers
- Medical Imaging/Radiology, Medical UltraSound Imaging Centre, Radboud Institute for Health Sciences, Radboud university medical center, the Netherlands
| | - Chris L. de Korte
- Medical Imaging/Radiology, Medical UltraSound Imaging Centre, Radboud Institute for Health Sciences, Radboud university medical center, the Netherlands
| | - Jacqueline Loonen
- Hematology, Radboud university medical center, Nijmegen, the Netherlands
| | | | | | - Leontien C.M. Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
- Pediatrics, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wouter E.M. Kok
- Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Livia Kapusta
- Pediatrics, Pediatric Cardiology Unit, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiology, Amalia Children’s Hospital, Radboud university medical center, Nijmegen, the Netherlands
| | - Dutch LATER Study Group
- Medical Imaging/Radiology, Medical UltraSound Imaging Centre, Radboud Institute for Health Sciences, Radboud university medical center, the Netherlands
- Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Cardiology, Radboud university medical center, Nijmegen, the Netherlands
- Pediatric Oncology, Amsterdam UMC, VU University, Amsterdam, the Netherlands
- Trial- and Data Center, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Pediatric Oncology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, the Netherlands
- Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
- Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
- Childhood Cancer Epidemiology/German Childhood Cancer Registry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
- Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Hematology, Radboud university medical center, Nijmegen, the Netherlands
- Pediatrics, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Pediatrics, Pediatric Cardiology Unit, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiology, Amalia Children’s Hospital, Radboud university medical center, Nijmegen, the Netherlands
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Demoor-Goldschmidt C, Allodji RS, Journy N, Rubino C, Zrafi WS, Debiche G, Llanas D, Veres C, Thomas-Teinturier C, Pacquement H, Vu-Bezin G, Fresneau B, Berchery D, Bolle S, Diallo I, Haddy N, de Vathaire F. Risk Factors for Small Adult Height in Childhood Cancer Survivors. J Clin Oncol 2020; 38:1785-1796. [PMID: 32196392 DOI: 10.1200/jco.19.02361] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Between 10% and 20% of childhood cancer survivors (CCS) experience impaired growth, leading to small adult height (SAH). Our study aimed to quantify risk factors for SAH or growth hormone deficiency among CCS. METHODS The French CCS Study holds data on 7,670 cancer survivors treated before 2001. We analyzed self-administered questionnaire data from 2,965 CCS with clinical, chemo/radiotherapy data from medical records. SAH was defined as an adult height ≤ 2 standard deviation scores of control values obtained from a French population health study. RESULTS After exclusion of 189 CCS treated with growth hormone, 9.2% (254 of 2,776) had a SAH. Being young at the time of cancer treatment (relative risk [RR], 0.91 [95% CI, 0.88 to 0.95] by year of age), small height at diagnosis (≤ 2 standard deviation scores; RR, 6.74 [95% CI, 4.61 to 9.86]), pituitary irradiation (5-20 Gy: RR, 4.24 [95% CI, 1.98 to 9.06]; 20-40 Gy: RR, 10.16 [95% CI, 5.18 to 19.94]; and ≥ 40 Gy: RR, 19.48 [95% CI, 8.73 to 43.48]), having received busulfan (RR, 4.53 [95% CI, 2.10 to 9.77]), or > 300 mg/m2 of lomustine (300-600 mg/m2: RR, 4.21 [95% CI, 1.61 to 11.01] and ≥ 600 mg/m2: RR, 9.12 [95% CI, 2.75 to 30.24]) were all independent risk factors for SAH. Irradiation of ≥ 7 vertebrae (≥ 15 Gy on ≥ 90% of their volume) without pituitary irradiation increased the RR of SAH by 4.62 (95% CI, 2.77 to 7.72). If patients had also received pituitary irradiation, this increased the RR by an additional factor of 1.3 to 2.4. CONCLUSION CCS are at a high risk of SAH. CCS treated with radiotherapy, busulfan, or lomustine should be closely monitored for growth, puberty onset, and potential pituitary deficiency.
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Affiliation(s)
- Charlotte Demoor-Goldschmidt
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Hematology Oncology Department, CHU Angers, Angers, France
| | - Rodrigue S Allodji
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Neige Journy
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Carole Rubino
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Wael Salem Zrafi
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Ghazi Debiche
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France
| | - Damien Llanas
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Cristina Veres
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Cécile Thomas-Teinturier
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France.,Department of Pediatric Endocrinology, APHP, Hôpitaux Paris-Sud, site Bicêtre, Le Kremlin Bicêtre, France
| | | | - Giao Vu-Bezin
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Brice Fresneau
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | | | - Stephanie Bolle
- Pediatric Oncology Department, Gustave Roussy, Villejuif, France
| | - Ibrahima Diallo
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Nadia Haddy
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Florent de Vathaire
- Cancer and Radiation Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Pediatric Oncology Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
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Kok HP, Van Dijk IWEM, Crama KF, Franken NAP, Rasch CRN, Merks JHM, Crezee J, Balgobind BV, Bel A. Re‑irradiation plus hyperthermia for recurrent pediatric sarcoma; a simulation study to investigate feasibility. Int J Oncol 2018; 54:209-218. [PMID: 30387837 DOI: 10.3892/ijo.2018.4622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/21/2018] [Indexed: 11/05/2022] Open
Abstract
Recurrent pediatric tumors pose a challenge since treatment options may be limited, particularly after previous irradiation. Positive results have been reported for chemotherapy and hyperthermia, but the combination of re‑irradiation and hyperthermia has not been investigated thus far, although it is a proven treatment strategy in adults. The theoretical feasibility of re‑irradiation plus hyperthermia was investigated for infield recurrent pediatric sarcoma in the pelvic region and the extremities. A total of 46 recurrent pediatric sarcoma cases diagnosed at the Academic Medical Center (Amsterdam, The Netherlands) between 2002 and 2017 were evaluated. Patients not previously irradiated, outfield recurrences and locations other than the pelvis and extremities were excluded, ultimately yielding four eligible patients: Two with sarcomas in the pelvis and two in an extremity. Re‑irradiation and hyperthermia treatment plans were simulated for 23x2 Gy treatment schedules and weekly hyperthermia. The radiosensitizing effect of hyperthermia was quantified using biological modelling with a temperature‑dependent change in the parameters of the linear‑quadratic model. The possible effectiveness of re‑irradiation plus hyperthermia was estimated by calculating the equivalent radiotherapy dose distribution. Treatment planning revealed that tumors located in the pelvis and the extremities can be effectively heated in children. Equivalent dose distributions indicated that hyperthermic radiosensitization can be quantified as a target‑selective additional D95% of typically 10 Gy, thereby delivering a possibly curative dose of 54 Gy, without substantially increasing the equivalent dose to the organs at risk. Therefore, re‑irradiation plus hyperthermia is a theoretically feasible and possibly effective treatment option for recurrent pediatric sarcoma in the pelvic region and the extremities, and its clinical feasibility is worthy of evaluation.
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Affiliation(s)
- H Petra Kok
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Irma W E M Van Dijk
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Koen F Crama
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Nicolaas A P Franken
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Coen R N Rasch
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Johannes H M Merks
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Johannes Crezee
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Brian V Balgobind
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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4
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Heart volume reduction during radiotherapy involving the thoracic region in children: An unexplained phenomenon. Radiother Oncol 2018; 128:214-220. [PMID: 29703501 DOI: 10.1016/j.radonc.2018.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 03/06/2018] [Accepted: 04/06/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Radiotherapy involving the thoracic region is associated with cardiotoxicity in long-term childhood cancer survivors. We quantified heart volume changes during radiotherapy in children (<18 years) and investigated correlations with patient and treatment related characteristics. MATERIAL AND METHODS Between 2010 and 2016, 34 children received radiotherapy involving the thoracic region. We delineated heart contours and measured heart volumes on 114 CBCTs. Relative volume changes were quantified with respect to the volume on the first CBCT (i.e., 100%). Cardiac radiation dose parameters expressed as 2 Gy/fraction equivalent doses were calculated from DVHs. Chemotherapy was categorized as treatment with anthracyclines, alkylating agents, vinca-alkaloids, and other. RESULTS The overall median heart volume reduction from the first to the last CBCT was 5.5% (interquartile range1.6-9.7%; p < 0.001). Heart volumes decreased significantly between the baseline measurement and the first week (Bonferroni's adjusted p = 0.002); volume changes were not significant during the following weeks. Univariate analysis showed a significant correlation between heart volume reduction and alkylating agents; however, no multivariate analyses could be done to further confirm this. CONCLUSIONS We found a significant heart volume reduction in children during radiotherapy. Elucidation of underlying mechanisms, clinical relevance, and possible long-term consequences of early heart volume reduction require a prospective follow-up study.
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van Dijk IWEM, van der Pal HJH, van Os RM, Roos YBWEM, Sieswerda E, van Dalen EC, Ronckers CM, Oldenburger F, van Leeuwen FE, Caron HN, Koning CCE, Kremer LCM. Risk of Symptomatic Stroke After Radiation Therapy for Childhood Cancer: A Long-Term Follow-Up Cohort Analysis. Int J Radiat Oncol Biol Phys 2016; 96:597-605. [PMID: 27325477 DOI: 10.1016/j.ijrobp.2016.03.049] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/29/2016] [Accepted: 03/24/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Long-term childhood cancer survivors are at high risk of late adverse effects, including stroke. We aimed to determine the cumulative incidence of clinically validated symptomatic stroke (transient ischemic attack [TIA], cerebral infarction, and intracerebral hemorrhage [ICH]) and to quantify dose-effect relationships for cranial radiation therapy (CRT) and supradiaphragmatic radiation therapy (SDRT). METHODS AND MATERIALS Our single-center study cohort included 1362 survivors of childhood cancer that were diagnosed between 1966 and 1996. Prescribed CRT and SDRT doses were converted into the equivalent dose in 2-Gy fractions (EQD2). Multivariate Cox regression models were used to analyze the relationship between the EQD2 and stroke. RESULTS After a median latency time of 24.9 years and at a median age of 31.2 years, 28 survivors had experienced a first stroke: TIA (n=5), infarction (n=13), and ICH (n=10). At an attained age of 45 years, the estimated cumulative incidences, with death as competing risk, among survivors treated with CRT only, SDRT only, both CRT and SDRT, and neither CRT nor SDRT were, respectively, 10.0% (95% confidence interval [CI], 2.5%-17.0%), 5.4% (95% CI, 0%-17.0%), 12.5% (95% CI, 5.5%-18.9%), and 0.1% (95% CI, 0%-0.4%). Radiation at both locations significantly increased the risk of stroke in a dose-dependent manner (hazard ratios: HRCRT 1.02 Gy(-1); 95% CI, 1.01-1.03, and HRSDRT 1.04 Gy(-1); 95% CI, 1.02-1.05). CONCLUSIONS Childhood cancer survivors treated with CRT, SDRT, or both have a high stroke risk. One in 8 survivors treated at both locations will have experienced a symptomatic stroke at an attained age of 45 years. Further research on the pathophysiologic processes involved in stroke in this specific group of patients is needed to enable the development of tailored secondary prevention strategies.
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Affiliation(s)
- Irma W E M van Dijk
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Helena J H van der Pal
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands; Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Rob M van Os
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Elske Sieswerda
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands; Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Elvira C van Dalen
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Cécile M Ronckers
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Foppe Oldenburger
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Academic Medical Center, Amsterdam, The Netherlands
| | - Huib N Caron
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Caro C E Koning
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Leontien C M Kremer
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
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