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Papangelopoulou D, Bison B, Behrens L, Bailey S, Ansari M, Ehlert K, Martinez OC, Kramm CM, Morales La Madrid A, von Bueren AO. Brain stem tumors in children less than 3 months: Clinical and radiologic findings of a rare disease. Childs Nerv Syst 2024; 40:1053-1064. [PMID: 38376530 DOI: 10.1007/s00381-023-06272-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/26/2023] [Indexed: 02/21/2024]
Abstract
PURPOSE Brain stem tumors in children < 3 months at diagnosis are extremely rare. Our aim is to study a retrospective cohort to improve the understanding of the disease course and guide patient management. METHODS This is a multicenter retrospective analysis across the European Society for Pediatric Oncology SIOP-E HGG/DIPG Working Group linked centers, including patients with a brainstem tumor diagnosed between 2009 and 2020 and aged < 3 months at diagnosis. Clinical data were collected, and imaging characteristics were analyzed blindly and independently by two neuroradiologists. RESULTS Five cases were identified. No patient received any therapy. The epicenter of two tumors was in the medulla oblongata alone and in the medulla oblongata and the pons in three. For patients with tumor in equal parts in the medulla oblongata and the pons (n = 3), the extension at diagnosis involved the spinal cord; for the two patients with the tumor epicenter in the medulla oblongata alone (n = 2), the extension at diagnosis included the pons (n = 2) and the spinal cord (n = 1). Biopsy was performed in one patient identifying a pilocytic astrocytoma. Two patients died. In one patient, autopsy revealed a high-grade glioma (case 3). Three survivors showed either spontaneous tumor regression (n = 2) or stable disease (n = 1). Survivors were followed up for 10, 7, and 0.6 years, respectively. One case had the typical imaging characteristics of a dorsal exophytic low-grade glioma. CONCLUSIONS No patient fulfilled the radiologic criteria defining a high-grade glioma. Central neuroradiological review and biopsy may provide useful information regarding the patient management.
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Affiliation(s)
- Danai Papangelopoulou
- Department of Pediatrics, Gynecology and Obstetrics, Division of General Pediatrics, Pediatric Hematology and Oncology Unit, University Hospitals of Geneva, Geneva, Switzerland
- Cansearch Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Brigitte Bison
- Diagnostic and Interventional Neuroradiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Lars Behrens
- Diagnostic and Interventional Neuroradiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Simon Bailey
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne, UK
| | - Marc Ansari
- Department of Pediatrics, Gynecology and Obstetrics, Division of General Pediatrics, Pediatric Hematology and Oncology Unit, University Hospitals of Geneva, Geneva, Switzerland
- Cansearch Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Karoline Ehlert
- Department of Pediatric Hematology and Oncology, University Medicine Greifswald, Greifswald, Germany
| | | | - Christof M Kramm
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, University Medical Center Goettingen, Goettingen, Germany
| | | | - Andre O von Bueren
- Department of Pediatrics, Gynecology and Obstetrics, Division of General Pediatrics, Pediatric Hematology and Oncology Unit, University Hospitals of Geneva, Geneva, Switzerland.
- Cansearch Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland.
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Rechberger JS, Bouchal SM, Power EA, Nonnenbroich LF, Nesvick CL, Daniels DJ. Bench-to-bedside investigations of H3 K27-altered diffuse midline glioma: drug targets and potential pharmacotherapies. Expert Opin Ther Targets 2023; 27:1071-1086. [PMID: 37897190 PMCID: PMC11079776 DOI: 10.1080/14728222.2023.2277232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/26/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION H3 K27-altered diffuse midline glioma (DMG) is the most common malignant brainstem tumor in the pediatric population. Despite enormous preclinical and clinical efforts, the prognosis remains dismal, with fewer than 10% of patients surviving for two years after diagnosis. Fractionated radiation remains the only standard treatment options for DMG. Developing novel treatments and therapeutic delivery methods is critical to improving outcomes in this devastating disease. AREAS COVERED This review addresses recent advances in molecularly targeted pharmacotherapy and immunotherapy in DMG. The clinical presentation, diagnostic workup, unique pathological challenges, and current clinical trials are highlighted throughout. EXPERT OPINION Promising pharmacotherapies targeting various components of DMG pathology and the application of immunotherapies have the potential to improve patient outcomes. However, novel approaches are needed to truly revolutionize treatment for this tumor. First, combinational therapy should be employed, as DMG can develop resistance to single-agent approaches and many therapies are susceptible to rapid clearance from the brain. Second, drug-tumor residence time, i.e. the time for which a therapeutic is present at efficacious concentrations within the tumor, must be maximized to facilitate a durable treatment response. Engineering extended drug delivery methods with minimal off-tumor toxicity should be a focus of future studies.
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Affiliation(s)
- Julian S. Rechberger
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
| | - Samantha M. Bouchal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
| | - Erica A. Power
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Leo F. Nonnenbroich
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Hopp Children’s Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Cody L. Nesvick
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David J. Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
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Fiz F, Bottoni G, Ugolini M, Righi S, Cirone A, Garganese MC, Verrico A, Rossi A, Milanaccio C, Ramaglia A, Mastronuzzi A, Abate ME, Cacchione A, Gandolfo C, Colafati GS, Garrè ML, Morana G, Piccardo A. Diagnostic and Dosimetry Features of [ 64Cu]CuCl 2 in High-Grade Paediatric Infiltrative Gliomas. Mol Imaging Biol 2023; 25:391-400. [PMID: 36042116 DOI: 10.1007/s11307-022-01769-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 03/12/2023]
Abstract
PURPOSE OF THE REPORT Paediatric diffuse high-grade gliomas (PDHGG) are rare central nervous system neoplasms lacking effective therapeutic options. Molecular imaging of tumour metabolism might identify novel diagnostic/therapeutic targets. In this study, we evaluated the distribution and the dosimetry aspects of [64Cu]CuCl2 in PDHGG subjects, as copper is a key element in cellular metabolism whose turnover may be increased in tumour cells. MATERIAL AND METHODS Paediatric patients with PDHGG were prospectively recruited. [64Cu]CuCl2 PET/CT was performed 1 h after tracer injection; if the scan was positive, it was repeated 24 and 72 h later. Lesion standardised uptake value (SUV) and target-to-background ratio (TBR) were calculated. Tumour and organ dosimetry were computed using the MIRD algorithm. Each patient underwent an MRI scan, including FLAIR, T2-weighted and post-contrast T1-weighted imaging. RESULTS Ten patients were enrolled (median age 9, range 6-16 years, 6 females). Diagnoses were diffuse midline gliomas (n = 8, 5 of which with H3K27 alterations) and diffuse hemispheric gliomas (n = 2). Six patients had visible tracer uptake (SUV: 1.0 ± 0.6 TBR: 5 ± 3.1). [64Cu]CuCl2 accumulation was always concordant with MRI contrast enhancement and was higher in the presence of radiological signs of necrosis. SUV and TBR progressively increased on the 24- and 72-h acquisitions (p < 0.05 and p < 0.01, respectively). The liver and the abdominal organs received the highest non-target dose. CONCLUSIONS [64Cu]CuCl2 is a well-tolerated radiotracer with reasonably favourable dosimetric properties, showing selective uptake in tumour areas with visible contrast enhancement and necrosis, thus suggesting that blood-brain barrier damage is a pre-requisite for its distribution to the intracranial structures. Moreover, tracer uptake showed an accumulating trend over time. These characteristics could deserve further analysis, to determine whether this radiopharmaceutical might have a possible therapeutic role as well.
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Affiliation(s)
- Francesco Fiz
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Galliera Hospital, Mura delle Cappuccine 14, 16128, Genoa, Italy.
| | - Gianluca Bottoni
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Galliera Hospital, Mura delle Cappuccine 14, 16128, Genoa, Italy
| | - Martina Ugolini
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Galliera Hospital, Mura delle Cappuccine 14, 16128, Genoa, Italy
| | - Sergio Righi
- Medical Physics Department, E.O. Galliera Hospital, Genoa, Italy
| | - Alessio Cirone
- Medical Physics Department, E.O. Galliera Hospital, Genoa, Italy
| | - Maria Carmen Garganese
- Nuclear Medicine Unit/Imaging Department, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Antonio Verrico
- Neuro-Oncology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | | | - Antonia Ramaglia
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Angela Mastronuzzi
- Neuro-Oncology Unit, Department of Paediatric Haematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | | | - Antonella Cacchione
- Neuro-Oncology Unit, Department of Paediatric Haematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Carlo Gandolfo
- Imaging Department, Neuroradiology Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | | | | | - Giovanni Morana
- Department of Neurosciences, University of Turin, Turin, Italy
| | - Arnoldo Piccardo
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Galliera Hospital, Mura delle Cappuccine 14, 16128, Genoa, Italy
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Vilela-Filho O, Porfírio J, Goulart LC. Indicators of correct targeting in stereotactic biopsy of intracranial lesions. Surg Neurol Int 2022; 13:251. [PMID: 35855128 PMCID: PMC9282734 DOI: 10.25259/sni_246_2022] [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: 03/11/2022] [Accepted: 05/29/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Confirmation of whether a stereotactic biopsy was performed in the correct site is usually dependent on the frozen section or on novel tumor-specific markers that are not widely available. Immediate postoperative computed tomography (CT) or magnetic resonance (MR) is routinely performed in our service after biopsy. In this retrospective study, we have carefully analyzed these images in an attempt to determine the presence of markers that indicate appropriate targeting.
Methods:
Medical records and neuroimages of patients who underwent stereotactic biopsy of intracranial lesions were reviewed. The following variables were assessed: age, sex, anatomopathology, lesion site, complications, diagnostic accuracy, and the presence of image markers.
Results:
Twenty-nine patients were included in this case series. About 96.6% of the biopsies were accurate according to the permanent section. Of the 86.2% of patients with intralesional pneumocephalus on the postoperative images, 51.7% additionally presented petechial hemorrhage. In 13.8% of the cases, no image markers were identified.
Conclusion:
This is the first report of intralesional pneumocephalus and petechial hemorrhage as indicators of appropriate targeting in stereotactic biopsy. In the majority of the cases, an immediate postoperative head CT, which is widely available, can estimate how adequate the targeting is. To use intralesional pneumocephalus/ petechial hemorrhages as not only postoperative but also as intraoperative markers of appropriate targeting, it is advised that the surgical wound should be temporarily closed and dressed after the biopsy so that the patient can undergo a CT/MR scan and be checked for the presence of theses markers before removing the stereotactic frame.
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Baquero-Herrera PE, Ardila-Martínez MA, Abdalá-Vargas NJ, Racedo J, Ordóñez-Rubiano EG. Treatment Limitations for Pediatric Diffuse Intrinsic Pontine Gliomas in a Middle-Income Country. J Neurosci Rural Pract 2022; 13:515-520. [PMID: 35945995 PMCID: PMC9357494 DOI: 10.1055/s-0042-1745714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Abstract
Objectives To evaluate the surgical management outcomes in pediatric patients with diffuse intrinsic pontine gliomas (DIPGs) who underwent intended biopsies and partial resections in a middle-income country, highlighting the barriers and challenges of these procedures for further investigation.
Methods A retrospective review of a prospective acquired series of patients who underwent biopsy or resection for DIPG between January 2012 and June 2018 at our institution was performed.
Results A total of 43 patients with posterior fossa tumors were identified. From these, seven pediatric DIPG cases were enrolled. Five were males. The median age was 5 years (range: 1–12 years). Only one patient (14.3%) had a ganglioglioma, while the others presented pilocytic and diffuse astrocytomas. Two (28.6%) patients had an intentional biopsy, and the other five (71.4%) had a partial resection. In the three (28.6%) patients who presented with associated hydrocephalus, the endoscopic third ventriculostomy was performed in the same surgical time. The median preoperative Lansky play-performance scale (LPPS) was 80 (range: 60–100), while the median postoperative LPPS was 23 (range: 7–52).
Conclusion A decrease in overall survival was noted compared with data reported in other series. Multifactorial barriers were discussed including the social, geographic, and economic features that may influence on final outcomes.
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Affiliation(s)
- Pablo E. Baquero-Herrera
- Department of Neurosurgery, Hospital Infantil Universitario de San José, Fundacion Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Manuel A. Ardila-Martínez
- Department of Neurosurgery, Hospital Infantil Universitario de San José, Fundacion Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
- Department of Neurosurgery, Hospital de San José – Sociedad de Cirugía de Bogotá, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Nadín J. Abdalá-Vargas
- Department of Neurosurgery, Hospital Infantil Universitario de San José, Fundacion Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
- Department of Neurosurgery, Hospital de San José – Sociedad de Cirugía de Bogotá, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
| | - Jorge Racedo
- microscopIA Research Group, microscopIA, Bogotá, Colombia
| | - Edgar G. Ordóñez-Rubiano
- Department of Neurosurgery, Hospital de San José – Sociedad de Cirugía de Bogotá, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
- Department of Biomedical Engineering, Universidad de Los Andes, Bogotá, Colombia
- Research Institute, Fundación Universitaria de Ciencias de la Salud (FUCS), Bogotá, Colombia
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Pediatric midline H3K27M-mutant tumor with disseminated leptomeningeal disease and glioneuronal features: case report and literature review. Childs Nerv Syst 2021; 37:2347-2356. [PMID: 32989496 DOI: 10.1007/s00381-020-04892-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND H3K27M-mutant midline lesions were recently reclassified by the World Health Organization (WHO) as "diffuse midline glioma" (DMG) based entirely on their molecular signature. DMG is one of the most common and most lethal pediatric brain tumors; terminal progression is typically caused by local midbrain or brainstem progression, or secondary leptomeningeal dissemination. H3K27M mutations have also been infrequently associated with a histologically and prognostically diverse set of lesions, particularly spinal masses with early leptomeningeal spread. CASE PRESENTATION A 15-year-old girl after 1 week of symptoms was found to have a T2/FLAIR-hyperintense and contrast-enhancing thalamic mass accompanied by leptomeningeal enhancement along the entire neuraxis. Initial infectious workup was negative, and intracranial biopsy was inconclusive. Spinal arachnoid biopsy revealed an H3K27M-mutant lesion with glioneuronal features, classified thereafter as DMG. She received craniospinal irradiation with a boost to the thalamic lesion. Imaging 1-month post-radiation demonstrated significant treatment response with residual enhancement at the conus. CONCLUSIONS This case report describes the unique presentation of an H3K27M-mutant midline lesion with significant craniospinal leptomeningeal spread on admission and atypical glioneuronal histopathological markers. With such florid leptomeningeal disease, spinal dural biopsy should be considered earlier given its diagnostic yield in classifying the lesion as DMG. Consistent with similar prior reports, this lesion additionally demonstrated synaptophysin positivity-also potentially consistent with a diagnosis of diffuse leptomeningeal glioneuronal tumor (DLGNT). In atypical DMG cases, particularly with leptomeningeal spread, further consideration of clinical and histopathological context is necessary for accurate diagnosis and prognostication.
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Srikanthan D, Taccone MS, Van Ommeren R, Ishida J, Krumholtz SL, Rutka JT. Diffuse intrinsic pontine glioma: current insights and future directions. Chin Neurosurg J 2021; 7:6. [PMID: 33423692 PMCID: PMC7798267 DOI: 10.1186/s41016-020-00218-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/24/2020] [Indexed: 02/06/2023] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a lethal pediatric brain tumor and the leading cause of brain tumor–related death in children. As several clinical trials over the past few decades have led to no significant improvements in outcome, the current standard of care remains fractionated focal radiation. Due to the recent increase in stereotactic biopsies, tumor tissue availabilities have enabled our advancement of the genomic and molecular characterization of this lethal cancer. Several groups have identified key histone gene mutations, genetic drivers, and methylation changes in DIPG, providing us with new insights into DIPG tumorigenesis. Subsequently, there has been increased development of in vitro and in vivo models of DIPG which have the capacity to unveil novel therapies and strategies for drug delivery. This review outlines the clinical characteristics, genetic landscape, models, and current treatments and hopes to shed light on novel therapeutic avenues and challenges that remain.
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Affiliation(s)
- Dilakshan Srikanthan
- Cell Biology Program, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Michael S Taccone
- Cell Biology Program, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Randy Van Ommeren
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada
| | - Joji Ishida
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada
| | - Stacey L Krumholtz
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada
| | - James T Rutka
- Cell Biology Program, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada. .,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada. .,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada. .,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada. .,Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Suite 1503, 555, University Avenue, Toronto, ON, M5G 1X8, Canada.
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