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Dávila Fajardo R, Scarzello G, Gaze MN, Boterberg T, Cameron A, Fuchs J, Guérin F, Hoskin P, Krasin MJ, Kroon P, Magelssen H, Mercke C, Merks JHM, Paulsen F, Pommier P, Ramos M, Rees H, Rogers T, Schmid M, Seitz G, Slater O, Smeulders N, Stenman J, Terwisscha S, Chargari C, Mandeville HC. Brachytherapy for rhabdomyosarcoma: Survey of international clinical practice and development of guidelines. Radiother Oncol 2024; 195:110273. [PMID: 38588921 DOI: 10.1016/j.radonc.2024.110273] [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: 11/15/2023] [Revised: 03/07/2024] [Accepted: 04/04/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to address the lack of published data on the use of brachytherapy in pediatric rhabdomyosarcoma by describing current practice as starting point to develop consensus guidelines. MATERIALS AND METHODS An international expert panel on the treatment of pediatric rhabdomyosarcoma comprising 24 (pediatric) radiation oncologists, brachytherapists and pediatric surgeons met for a Brachytherapy Workshop hosted by the European paediatric Soft tissue Sarcoma Study Group (EpSSG). The panel's clinical experience, the results of a previously distributed questionnaire, and a review of the literature were presented. RESULTS The survey indicated the most common use of brachytherapy to be in combination with tumor resection, followed by brachytherapy as sole local therapy modality. HDR was increasingly deployed in pediatric practice, especially for genitourinary sites. Brachytherapy planning was mostly by 3D imaging based on CT. Recommendations for patient selection, treatment requirements, implant technique, delineation, dose prescription, dose reporting and clinical management were defined. CONCLUSIONS Consensus guidelines for the use of brachytherapy in pediatric rhabdomyosarcoma have been developed through multicenter collaboration establishing the basis for future work. These have been adopted for the open EpSSG overarching study for children and adults with Frontline and Relapsed RhabdoMyoSarcoma (FaR-RMS).
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Affiliation(s)
- Raquel Dávila Fajardo
- Department of Radiation Oncology, University Medical Center, Utrecht, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Division Imaging and Oncology, University Medical Center, Utrecht, the Netherlands.
| | | | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.
| | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium.
| | - Alison Cameron
- Bristol Cancer Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom.
| | - Joerg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Childreńs Hospital, Tuebingen, Germany
| | - Florent Guérin
- Department of Paediatric Surgery, Paris-Saclay University, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Paris, France
| | - Peter Hoskin
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.
| | - Matthew J Krasin
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, USA
| | - Petra Kroon
- Department of Radiation Oncology, University Medical Center, Utrecht, the Netherlands; Division Imaging and Oncology, University Medical Center, Utrecht, the Netherlands.
| | | | - Claes Mercke
- Department of Oncology-Pathology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
| | - Johannes H M Merks
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Division Imaging and Oncology, University Medical Center, Utrecht, the Netherlands.
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital, Tuebingen, Germany.
| | - Pascal Pommier
- Department of Radiation Oncology, Centre Leon Berard, Lyon, France.
| | - Monica Ramos
- Department of Radiation Oncology, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Helen Rees
- Bristol Cancer Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom.
| | - Tim Rogers
- Bristol Cancer Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Maximilian Schmid
- Medical University of Vienna, Department of Radiation Oncology, Comprehensive Cancer Center, Vienna, Austria.
| | - Guido Seitz
- Department of Pediatric Surgery and Urology, University Hospital Giessen-Marburg, Campus Marburg, Marburg, Germany.
| | - Olga Slater
- Department of Paediatric Oncology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.
| | - Naima Smeulders
- Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.
| | - Jakob Stenman
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
| | - Sheila Terwisscha
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Comprehensive Cancer Center, Villejuif, France.
| | - Henry C Mandeville
- The Royal Marsden Hospital and Institute of Cancer Research, Sutton, United Kingdom
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Ballantyne E, Evans C, Shepherd L, Fulbright H, Wakeling S, Phillips B, Morgan JE. A systematic review of combined surgery and brachytherapy approaches for children and young people with relapsed and refractory rhabdomyosarcoma (Local-REFoRMS). Pediatr Blood Cancer 2024; 71:e30952. [PMID: 38566349 DOI: 10.1002/pbc.30952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/27/2024] [Accepted: 03/02/2024] [Indexed: 04/04/2024]
Abstract
Approximately one third of children with rhabdomyosarcoma relapse or have refractory disease. Treatment approaches include a combination of systemic therapies and local therapies, directed at tumour site(s). This review was conducted to evaluate the effectiveness and safety of the combination of surgery and brachytherapy as local therapy for treating children and young people with relapsed/refractory rhabdomyosarcoma. This review identified studies based on a previous systematic review looking at the treatments for children and young people under 18 years old with relapsed/refractory rhabdomyosarcoma. Studies conducted after 2000 were included. Survival outcomes, relapse rates, adverse events and functional outcomes were extracted. From 16,965 records identified in the baseline systematic review, 205 included the words 'AMORE' or 'brachytherapy', and were screened for eligibility in this substudy. Thirteen studies met the inclusion criteria for Local-REFoRMS, including over 55 relapsed and refractory rhabdomyosarcoma patients. Most studies were retrospective cohort studies conducted within Europe. Most patients had embryonal disease within the head and neck or bladder/prostate regions, and received local therapy for first relapse. Approximately one quarter of patients relapsed following surgery and brachytherapy, with local relapses occurring more than metastatic relapse. Adverse events and functional outcomes were infrequently reported, but related to the site of surgery and brachytherapy. Study quality was limited by inconsistent reporting and potential selection bias. Outcomes following surgery and brachytherapy for a selected group of relapsed and refractory rhabdomyosarcoma show reasonable benefits, but reporting was often unclear and based on small sample sizes.
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Affiliation(s)
- Euan Ballantyne
- Calderdale and Huddersfield Foundation Trust, Lindley, Huddersfield, UK
| | - Connor Evans
- Centre for Reviews and Dissemination, University of York, Heslington, York, UK
| | - Lucy Shepherd
- Centre for Reviews and Dissemination, University of York, Heslington, York, UK
| | - Helen Fulbright
- Centre for Reviews and Dissemination, University of York, Heslington, York, UK
| | | | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, Heslington, York, UK
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital NHS Trust, Leeds, UK
| | - Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, Heslington, York, UK
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital NHS Trust, Leeds, UK
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3
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Zhang G, Sun N, Ni X, Su Y, He L, Liu Z, Zhang J, Li Y, Zhang X, Liu Q, Liu Z, Li X, Mei L, Liu Y, Ji T, Wang S. Treatment of nasolabial fold rhabdomyosarcoma in children: A single-institution experience. Head Neck 2024; 46:905-914. [PMID: 38214480 DOI: 10.1002/hed.27637] [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: 04/26/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVES To summarize the clinical characteristics and prognosis of children with nasolabial fold rhabdomyosarcoma (RMS). METHODS Retrospective review of children treated for nasolabial fold RMS from January 2014 to September 2019. RESULTS Of 21 patients with nasolabial fold RMS, 90.48% were alveolar subtype, in which PAX3/7-FOXO1 fusion positive accounted for 87.5%. Ten patients (47.62%) had nodals invasion. Almost all patients received comprehensive treatment (chemotherapy [100%], radiation therapy [100%], and surgery [95.24%]). The median follow-up time was 34.3 months. The 3-year overall survival (OS) and event-free survival (EFS) was 67.7% ± 14.1% and 42.1% ± 13.5%, respectively. Four patients had regional lymph node relapse (NR), all in the ipsilateral submandibular lymph node region. CONCLUSION Majority of the patients with RMS in the nasolabial fold area were alveolar subtype and had positive PAX3/7-FOXO1 gene fusion. In addition, the nasolabial fold RMS had a high probability of regional lymph node metastasis in the submandibular area. To maintain the facial aesthetics and functions, the surgical area for nasolabial fold RMS is often very conservative and restricted. This could be one of the contributors for the poor prognosis of nasolabial fold RMS beside its worse pathological subtype and gene fusion.
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Affiliation(s)
- Ge Zhang
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Nian Sun
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xin Ni
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Beijing Key Laboratory for Pediatric Diseases of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yan Su
- Department of Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lejian He
- Department of Pathology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhikai Liu
- Department of Radiotherapy, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jie Zhang
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yanzhen Li
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xuexi Zhang
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Qiaoyin Liu
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhiyong Liu
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaodan Li
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lin Mei
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yuwei Liu
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Tingting Ji
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shengcai Wang
- Department of Otolaryngology - Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Pezzulla D, Di Franco R, Zamagni A, Pastore F, Longo S, Dominici L, Lillo S, Ciabattoni A, Arcidiacono F, Deodato F, Muto P, Morganti AG, Cellini F, Maranzano E. Radiotherapy of orbital metastases: a systematic review of management and treatment outcomes on behalf of palliative care study group of Italian association of radiotherapy and clinical oncology (AIRO). Br J Radiol 2023; 96:20230124. [PMID: 37751164 PMCID: PMC10607395 DOI: 10.1259/bjr.20230124] [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: 02/07/2023] [Revised: 07/09/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVES We search the current literature on data regarding the role of RT in OM treatment, focusing on the improvement of symptoms and patient quality of life. METHODS This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. RESULTS From 340 citations, 60 papers were finally selected: 45 case reports and 15 case series. The case reports accounted for 47 patients. In 37/39 cases (95%), EBRT was done. Patients were mainly treated with 3DCRT, IMRT, and with SBRT. The most used RT regimens were 30 Gy in 10 fractions (23%) and 20-25 Gy in 5 fx (13%). No sever toxicity was reported. A median LC of 11 months (range 1-54 months) and a median OS of 12 months (range 1-54 months) were registered. Among the case series, a total of 457 patients were examined, 227 of whom underwent RT. The main used techniques were 3DCRT, CK, GK, SBRT, and BRT. RT doses could vary from 30 Gy/10 fractions to 60 Gy/30 fractions, 50 Gy/5 fractions, or 16.5-21 Gy in single fraction. No toxicity above G2 was reported. ORR could vary between 75 and 100%. Only two study provided information on response duration: a mean LC time of 22.8 months and a mean time to local progression of 5 months (range: 3-7). Regarding OS, the data were heterogeneous, ranging between 1 and 54 months. CONCLUSIONS RT for OM seems to be a safe and feasible option. More information on the RT ideal techniques and dose are still needed. ADVANCES IN KNOWLEDGE This paper tried to sum up the few and fragmented data on the use of radiotherapy for orbital metastases: the possible option ranged from 3D- and 2D-CRT to SBRT, CK, and GK, with different possible fractionations (30Gy in 10 fractions, 60 Gy/30 fractions, 20-50 Gy/5 fractions, or 16.5-21 Gy in single fraction). Regardless of the chosen approach, almost all treated patients experienced a benefit after RT in terms of OM-related symptom intensity reduction and a good acute and late toxicity profile.
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Affiliation(s)
- Donato Pezzulla
- Radiation Oncology Unit, Responsible Research Hospital, Largo A. Gemelli 1, Campobasso, Italy
| | - Rossella Di Franco
- Department of Radiation Oncology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Naples, Italy
| | - Alice Zamagni
- Radiation Oncology, Department of Experimental Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum-Bologna University, Bologna, Italy
| | - Francesco Pastore
- Dipartimento di Diagnostica Per Immagini, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Rome, Italy
| | - Silvia Longo
- Dipartimento di Diagnostica Per Immagini, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Rome, Italy
| | - Luca Dominici
- Department of Radiotherapy, Humanitas Clinical and Research Center–IRCCS, Rozzano, Milan, Italy
| | - Sara Lillo
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | | | | | | | - Paolo Muto
- Department of Radiation Oncology, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Naples, Italy
| | | | - Francesco Cellini
- Dipartimento di Diagnostica Per Immagini, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Rome, Italy
| | - Ernesto Maranzano
- University of Perugia-Faculty of Medicine and Surgery Radiotherapy Oncology Centre-“S. Maria” Hospital, Terni, Italy
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Vennarini S, Colombo F, Mirandola A, Chiaravalli S, Orlandi E, Massimino M, Casanova M, Ferrari A. Clinical Insight on Proton Therapy for Paediatric Rhabdomyosarcoma. Cancer Manag Res 2023; 15:1125-1139. [PMID: 37842128 PMCID: PMC10576457 DOI: 10.2147/cmar.s362664] [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: 07/17/2023] [Accepted: 10/05/2023] [Indexed: 10/17/2023] Open
Abstract
This paper offers an insight into the use of Proton Beam Therapy (PBT) in paediatric patients with rhabdomyosarcoma (RMS). This paper provides a comprehensive analysis of the literature, investigating comparative photon-proton dosimetry, outcome, and toxicity. In the complex and multimodal scenario of the treatment of RMS, clear evidence of the therapeutic superiority of PBT compared to other modern photon techniques has not yet been demonstrated; however, PBT can be considered an excellent treatment option, in particular for young children and patients with specific primary sites, such as the head and neck area (and especially the parameningeal regions), genito-urinary, pelvic, and paravertebral regions. The unique depth-dose characteristics of protons can be exploited to achieve significant reductions in normal tissue doses and may allow an escalation of tumour doses and greater sparing of normal tissues, thus potentially improving local control while at the same time reducing toxicity and improving quality of life. However, access of children with RMS (and more in general with solid tumors) to PBT remains a challenge, due to the limited number of available proton therapy installations.
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Affiliation(s)
- Sabina Vennarini
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Francesca Colombo
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
- Department of Oncology and Hemato-Oncology (DIPO), University of Milan, Milan, Italy
| | - Alfredo Mirandola
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Stefano Chiaravalli
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Maura Massimino
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Michela Casanova
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
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Gaze MN, Smeulders N, Ackwerh R, Allen C, Bal N, Boutros M, Cho A, Eminowicz G, Gill E, Fittall MW, Humphries PD, Lim P, Mushtaq I, Nguyen T, Peet C, Pendse D, Polhill S, Rees H, Sands G, Shankar A, Slater O, Sullivan T, Hoskin PJ. A National Referral Service for Paediatric Brachytherapy: An Evolving Practice and Outcomes Over 13 Years. Clin Oncol (R Coll Radiol) 2023; 35:237-244. [PMID: 36588012 DOI: 10.1016/j.clon.2022.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/15/2022] [Indexed: 01/01/2023]
Abstract
AIMS Most children requiring radiotherapy receive external beam treatment and few have tumours suitable for brachytherapy. No paediatric radiotherapy centre will treat enough patients from its own normal catchment population for expertise in brachytherapy to be developed and sustained. Following discussion and agreement in the national paediatric radiotherapy group, a service for paediatric brachytherapy in the UK has been developed. We report the process that has evolved over more than 10 years, with survival and functional outcome results. MATERIALS AND METHODS Since 2009, potential patients have been referred to the central paediatric oncology multidisciplinary team meeting, where imaging, pathology and treatment options are discussed. Since 2013, the National Soft Tissue Sarcoma Advisory Panel has also reviewed most patients, with the principal aim of advising on the most suitable primary tumour management for complex patients. Clinical assessment and examination under anaesthetic with biopsies may be undertaken to confirm the appropriateness of brachytherapy, either alone or following conservative surgery. Fractionated high dose rate brachytherapy was delivered to a computed tomography planned volume after implantation of catheters under ultrasound imaging guidance. Since 2019, follow-up has been in a dedicated multidisciplinary clinic. RESULTS From 2009 to 2021 inclusive, 35 patients (16 female, 19 male, aged 8 months to 17 years 6 months) have been treated. Histology was soft-tissue sarcoma in 33 patients and carcinoma in two. The treated site was pelvic in 31 patients and head and neck in four. With a median follow-up of 5 years, the local control and overall survival rates are 100%. Complications have been few, and functional outcome is good. CONCLUSION Brachytherapy is effective for selected paediatric patients, resulting in excellent tumour control and good functional results. It is feasible to deliver paediatric brachytherapy at a single centre within a national referral service.
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Affiliation(s)
- M N Gaze
- University College London Hospitals NHS Foundation Trust, London, UK; Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - N Smeulders
- University College London Hospitals NHS Foundation Trust, London, UK; Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - R Ackwerh
- University College London Hospitals NHS Foundation Trust, London, UK
| | - C Allen
- University College London Hospitals NHS Foundation Trust, London, UK
| | - N Bal
- University College London Hospitals NHS Foundation Trust, London, UK
| | - M Boutros
- University College London Hospitals NHS Foundation Trust, London, UK
| | - A Cho
- University College London Hospitals NHS Foundation Trust, London, UK; Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - G Eminowicz
- University College London Hospitals NHS Foundation Trust, London, UK
| | - E Gill
- University College London Hospitals NHS Foundation Trust, London, UK
| | - M W Fittall
- University College London Hospitals NHS Foundation Trust, London, UK
| | - P D Humphries
- University College London Hospitals NHS Foundation Trust, London, UK
| | - P Lim
- University College London Hospitals NHS Foundation Trust, London, UK; Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - I Mushtaq
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - T Nguyen
- University College London Hospitals NHS Foundation Trust, London, UK
| | - C Peet
- University College London Hospitals NHS Foundation Trust, London, UK
| | - D Pendse
- University College London Hospitals NHS Foundation Trust, London, UK
| | - S Polhill
- University College London Hospitals NHS Foundation Trust, London, UK
| | - H Rees
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - G Sands
- University College London Hospitals NHS Foundation Trust, London, UK
| | - A Shankar
- University College London Hospitals NHS Foundation Trust, London, UK
| | - O Slater
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - T Sullivan
- University College London Hospitals NHS Foundation Trust, London, UK
| | - P J Hoskin
- University College London Hospitals NHS Foundation Trust, London, UK
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7
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de Vries ISA, van Ewijk R, Adriaansen LME, Bohte AE, Braat AJAT, Fajardo RD, Hiemcke-Jiwa LS, Hol MLF, Ter Horst SAJ, de Keizer B, Knops RRG, Meister MT, Schoot RA, Smeele LE, van Scheltinga ST, Vaarwerk B, Merks JHM, van Rijn RR. Imaging in rhabdomyosarcoma: a patient journey. Pediatr Radiol 2023; 53:788-812. [PMID: 36843091 PMCID: PMC10027795 DOI: 10.1007/s00247-023-05596-8] [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: 08/30/2022] [Revised: 10/06/2022] [Accepted: 01/10/2023] [Indexed: 02/28/2023]
Abstract
Rhabdomyosarcoma, although rare, is the most frequent soft tissue sarcoma in children and adolescents. It can present as a mass at nearly any site in the body, with most common presentations in the head and neck, genitourinary tract and extremities. The optimal diagnostic approach and management of rhabdomyosarcoma require a multidisciplinary team with multimodal treatment, including chemotherapy and local therapy. Survival has improved over the last decades; however, further improvement in management is essential with current 5-year overall survival ranging from 35% to 100%, depending on disease and patient characteristics. In the full patient journey, from diagnosis, staging, management to follow-up after therapy, the paediatric radiologist and nuclear physician are essential members of the multidisciplinary team. Recently, guidelines of the European paediatric Soft tissue sarcoma Study Group, the Cooperative Weichteilsarkom Studiengruppe and the Oncology Task Force of the European Society of Paediatric Radiology (ESPR), in an ongoing collaboration with the International Soft-Tissue Sarcoma Database Consortium, provided guidance for high-quality imaging. In this educational paper, given as a lecture during the 2022 postgraduate ESPR course, the multi-disciplinary team of our national paediatric oncology centre presents the journey of two patients with rhabdomyosarcoma and discusses the impact on and considerations for the clinical (paediatric) radiologist and nuclear physician. The key learning points of the guidelines and their implementation in clinical practice are highlighted and up-to-date insights provided for all aspects from clinical suspicion of rhabdomyosarcoma and its differential diagnosis, to biopsy, staging, risk stratification, treatment response assessment and follow-up.
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Affiliation(s)
| | - Roelof van Ewijk
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Laura M E Adriaansen
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Anneloes E Bohte
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Arthur J A T Braat
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Raquel Dávila Fajardo
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Radiotherapy, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Laura S Hiemcke-Jiwa
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pathology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Marinka L F Hol
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Otorhinolaryngology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Simone A J Ter Horst
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Bart de Keizer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Rutger R G Knops
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Michael T Meister
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Oncode Institute, Utrecht, the Netherlands
| | - Reineke A Schoot
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Ludi E Smeele
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute (NCI), Amsterdam, the Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Bas Vaarwerk
- Department of Paediatrics, Amsterdam UMC - Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Amsterdam UMC - Emma Children's Hospital, University of Amsterdam, Suite C1-423.1, Meibergdreef 9, 1105AZ, Amsterdam, the Netherlands.
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8
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Di Carlo D, Chisholm J, Kelsey A, Alaggio R, Bisogno G, Minard-Colin V, Jenney M, Dávila Fajardo R, Merks JHM, Shipley JM, Selfe JL. Biological Role and Clinical Implications of MYOD1L122R Mutation in Rhabdomyosarcoma. Cancers (Basel) 2023; 15:cancers15061644. [PMID: 36980529 PMCID: PMC10046495 DOI: 10.3390/cancers15061644] [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: 01/15/2023] [Revised: 02/13/2023] [Accepted: 03/02/2023] [Indexed: 03/30/2023] Open
Abstract
Major progress in recent decades has furthered our clinical and biological understanding of rhabdomyosarcoma (RMS) with improved stratification for treatment based on risk factors. Clinical risk factors alone were used to stratify patients for treatment in the European Pediatric Soft Tissue Sarcoma Study Group (EpSSG) RMS 2005 protocol. The current EpSSG overarching study for children and adults with frontline and relapsed rhabdomyosarcoma (FaR-RMS NCT04625907) includes FOXO1 fusion gene status in place of histology as a risk factor. Additional molecular features of significance have recently been recognized, including the MYOD1L122R gene mutation. Here, we review biological information showing that MYOD1L122R blocks cell differentiation and has a MYC-like activity that enhances tumorigenesis and is linked to an aggressive cellular phenotype. MYOD1L122R mutations can be found together with mutations in other genes, such as PIK3CA, as potentially cooperating events. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, ten publications in the clinical literature involving 72 cases were reviewed. MYOD1L122R mutation in RMS can occur in both adults and children and is frequent in sclerosing/spindle cell histology, although it is also significantly reported in a subset of embryonal RMS. MYOD1L122R mutated tumors most frequently arise in the head and neck and extremities and are associated with poor outcome, raising the issue of how to use MYOD1L122R in risk stratification and how to treat these patients most effectively.
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Affiliation(s)
- Daniela Di Carlo
- Department of Women's and Children's Health, University of Padova, 35128 Padua, Italy
- Pediatric Hematology-Oncology Division, University Hospital of Padova, 35128 Padova, Italy
| | - Julia Chisholm
- Children and Young People's Unit, Royal Marsden Hospital, Institute of Cancer Research, Sutton SM2 5NG, UK
| | - Anna Kelsey
- Department of Pediatric Histopathology, Manchester University Foundation Trust, Manchester M13 9WL, UK
| | - Rita Alaggio
- Pathology Unit, Department of Laboratories, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Gianni Bisogno
- Department of Women's and Children's Health, University of Padova, 35128 Padua, Italy
- Pediatric Hematology-Oncology Division, University Hospital of Padova, 35128 Padova, Italy
| | - Veronique Minard-Colin
- Department of Pediatric and Adolescent Oncology, INSERM U1015, Gustave Roussy, Université Paris-Saclay, 94800 Villejuif, France
| | - Meriel Jenney
- Department of Pediatric Oncology, Children's Hospital for Wales, Cardiff CF14 4XW, UK
| | - Raquel Dávila Fajardo
- Department of Radiation Oncology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
| | - Johannes H M Merks
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Janet M Shipley
- Sarcoma Molecular Pathology Team, Divisions of Molecular Pathology and Cancer Therapeutics, The Institute of Cancer Research, London SM2 5NG, UK
| | - Joanna L Selfe
- Sarcoma Molecular Pathology Team, Divisions of Molecular Pathology and Cancer Therapeutics, The Institute of Cancer Research, London SM2 5NG, UK
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9
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Castle JT, Levy BE, Rodeberg DA. Abdominal Tumors. Surg Clin North Am 2022; 102:715-737. [DOI: 10.1016/j.suc.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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10
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Casey DL, Mandeville H, Bradley JA, Ter Horst SAJ, Sheyn A, Timmermann B, Wolden SL. Local control of parameningeal rhabdomyosarcoma: An expert consensus guideline from the International Soft Tissue Sarcoma Consortium (INSTRuCT). Pediatr Blood Cancer 2022; 69:e29751. [PMID: 35484997 DOI: 10.1002/pbc.29751] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 12/19/2022]
Abstract
The International Soft Tissue Sarcoma Database Consortium (INSTRuCT) consists of a collaboration between the Children's Oncology Group (COG) Soft Tissue Sarcoma Committee, the European pediatric Soft Tissue Sarcoma Study Group (EpSSG), and the Cooperative Weichteilsarkom Studiengruppe (CWS). As part of the larger initiative of INSTRuCT to provide consensus expert opinions for clinical treatment of pediatric soft tissue sarcoma, we sought to provide updated, evidenced-based consensus guidelines for local treatment of parameningeal rhabdomyosarcoma using both existing literature as well as recommendations from the relevant cooperative group clinical trials. Overall, parameningeal rhabdomyosarcoma represents a distinctly challenging disease to treat, given its location near many critical structures in the head and neck, frequently advanced local presentation, and predilection for local failure. Definitive chemoradiation remains the standard treatment approach for parameningeal rhabdomyosarcoma, with surgery often limited to biopsy or salvage therapy for recurrent disease. In this consensus paper, we specifically discuss consensus guidelines and evidence for definitive local management with radiotherapy, with a focus on imaging for radiotherapy planning, dose and timing of radiation, approach for nodal irradiation, various radiation techniques, including proton therapy, and the limited role of surgical resection.
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Affiliation(s)
- Dana L Casey
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
| | - Henry Mandeville
- Royal Marsden NHS Foundation Trust, London, UK.,Institute of Cancer Research, London, UK
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - Simone A J Ter Horst
- Department of Radiology, University Medical Center Utrecht, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Anthony Sheyn
- Department of Surgery, Division of Otolaryngology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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11
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Long-term disease-free survival following salvage brachytherapy for recurrent pediatric rhabdomyosarcoma: Two case reports and review of relevant literature. Brachytherapy 2022; 21:494-500. [PMID: 35514002 DOI: 10.1016/j.brachy.2022.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Rhabdomyosarcoma (RMS) is the most common pediatric soft-tissue sarcoma, mostly involving the genitourinary (GU) tract, head and neck, and extremities. This study reports the long-term outcome of two infants with recurrent GU-RMS who underwent combination therapy with chemotherapy (ChT) and salvage brachytherapy (BT). METHODS AND MATERIALS An 18-month-old girl with vaginal bleeding and a 7-month-old boy with urinary retention presented with a diagnosis of vaginal, and bladder/prostate embryonal RMS, respectively. Surgical resection and ChT were done for both patients. However, both developed local recurrences after one year and subsequently, underwent second-line ChT and salvage interstitial high dose rate BT. RESULTS The clinical target volumes for the first and second patients were treated to a totaldose of 32 Gy in 10 fractions and 35 Gy in 10 fractions, respectively, with two fractions delivered per day with a 6-h interval between fractions. After 9 years of follow-up, both patients are alive with natural growth and no late complication or evidence of recurrence. CONCLUSIONS Our report shows that BT (for patients with no prior history of irradiation) could result in long-term disease-free survival in well-selected pediatric patients with recurrent GU embryonal RMS without inflicting expected adverse effects of external beam radiotherapy.
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12
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American Brachytherapy Society (ABS) consensus statement for soft-tissue sarcoma brachytherapy. Brachytherapy 2021; 20:1200-1218. [PMID: 34303600 DOI: 10.1016/j.brachy.2021.05.011] [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: 04/17/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Growing data supports the role of radiation therapy in the treatment of soft tissue sarcoma (STS). Brachytherapy has been used for decades in the management of STS and can be utilized as monotherapy or as a boost to external beam radiation. We present updated guidelines from the American Brachytherapy Society regarding the utilization of brachytherapy in the management of STS. METHODS AND MATERIALS Members of the American Brachytherapy Society with expertise in STS and STS brachytherapy created an updated clinical practice guideline including step-by-step details for performing STS brachytherapy based on a literature review and clinical experience. RESULTS Brachytherapy monotherapy should be considered for lower-recurrence risk patients or after a local recurrence following previous external beam radiation; a brachytherapy boost can be considered in higher-risk patents meeting implant criteria. Multiple dose/fractionation regimens are available, with determination based on tumor location and treatment intent. Techniques to limit wound complications are based on the type of wound closure; wound complication can be mitigated with a delay in the start of brachytherapy with immediate wound closure or by utilizing a staged reconstruction technique, which allows an earlier treatment start with a delayed wound closure. CONCLUSIONS These updated guidelines provide clinicians with data on indications for STS brachytherapy as well as guidelines on how to perform and deliver high quality STS brachytherapy safely with minimal toxicity.
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Prasad D, Vern-Gross T, Wolden S. Radiosurgery, reirradiation, and brachytherapy. Pediatr Blood Cancer 2021; 68 Suppl 2:e28531. [PMID: 33818888 DOI: 10.1002/pbc.28531] [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: 01/28/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 11/05/2022]
Abstract
Radiosurgery and brachytherapy are potentially useful treatment techniques that are sparingly applied in pediatric oncology. They are often used in the setting of reirradiation for recurrent or metastatic tumors. Reirradiation in children with recurrent tumors is complicated by the tolerance of critical organs and the potential risks for overall long-term dose-dependent complications. We review the current literature available in support of reirradiation and the use of radiosurgery and brachytherapy in pediatric patients.
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Affiliation(s)
- Dheerendra Prasad
- Department of Radiation Oncology and Neurosurgery, Roswell Park Comprehensive Cancer Center and Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | | | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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14
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Heske CM, Mascarenhas L. Relapsed Rhabdomyosarcoma. J Clin Med 2021; 10:804. [PMID: 33671214 PMCID: PMC7922213 DOI: 10.3390/jcm10040804] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/02/2021] [Accepted: 02/13/2021] [Indexed: 12/14/2022] Open
Abstract
Relapsed rhabdomyosarcoma (RMS) represents a significant therapeutic challenge. Nearly one-third of patients diagnosed with localized RMS and over two-thirds of patients with metastatic RMS will experience disease recurrence following primary treatment, generally within three years. Clinical features at diagnosis, including primary site, tumor invasiveness, size, stage, and histology impact likelihood of relapse and prognosis post-relapse. Aspects of initial treatment, including extent of surgical resection, use of radiotherapy, and chemotherapy regimen, are also associated with post-relapse outcomes, as are features of the relapse itself, including time to relapse and extent of disease involvement. Although there is no standard treatment for patients with relapsed RMS, several general principles, including tissue biopsy confirmation of diagnosis, assessment of post-relapse prognosis, determination of the feasibility of additional local control measures, and discussion of patient goals, should all be part of the approach to care. Patients with features suggestive of a favorable prognosis, which include those with botryoid RMS or stage 1 or group I embryonal RMS (ERMS) who have had no prior treatment with cyclophosphamide, have the highest chance of achieving long-term cure when treated with a multiagent chemotherapy regimen at relapse. Unfortunately, patients who do not meet these criteria represent the majority and have poor outcomes when treated with such regimens. For this group, strong consideration should be given for enrollment on a clinical trial.
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Affiliation(s)
- Christine M. Heske
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Leo Mascarenhas
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Division of Hematology/Oncology, Department of Pediatrics and Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA;
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15
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Bompas E, Martin V, Meniai F, Toulmonde M, Marec-Berard P, Claude L, Ducimetiere F, Chargari C, Minard-Colin V, Corradini N, Laurence V, Piperno-Neumann S, Defachelles AS, Bernier V, Italiano A, Orbach D, Blay JY, Gaspar N, Berlanga P. Management of sarcomas in children, adolescents and adults: Interactions in two different age groups under the umbrellas of GSF-GETO and SFCE, with the support of the NETSARC+ network. Bull Cancer 2021; 108:163-176. [PMID: 33455736 DOI: 10.1016/j.bulcan.2020.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/17/2020] [Accepted: 10/27/2020] [Indexed: 11/17/2022]
Abstract
Sarcomas are a rare heterogeneous group of malignant neoplasms that can arise in almost any anatomic site and any age. Close collaboration among adult and pediatric cancer specialists in the management of these tumors is of foremost importance. In this review, we present the current multidisciplinary organization in care of patients with sarcoma in France and we review the main advances made in the last decades in systemic and radiotherapy treatment in the main sarcoma types diagnosed in children, adolescents and young adults (AYA), thanks to the international collaboration.
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Affiliation(s)
- Emmanuelle Bompas
- Centre René Gauducheau, Medical Oncology Department, Saint-Herblain, France
| | - Valentine Martin
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Fatima Meniai
- University Lille, Inserm, U1189 - ONCO-THAI - Assisted Laser Therapy and Immunotherapy for Oncology, 59000 Lille, France
| | - Maud Toulmonde
- Institut Bergonié, Medical Oncology Department, Bordeaux, France
| | | | - Line Claude
- Centre Léon Bérard, Department of radiotherapy, Lyon, France
| | | | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | | | - Nadège Corradini
- Centre Léon Bérard, Department of Pediatric Oncology, Lyon, France
| | | | | | | | - Valérie Bernier
- Oncology Radiotherapy Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France
| | | | - Daniel Orbach
- Department of Pediatric Oncology, Institut Curie, Paris, France
| | - Jean-Yves Blay
- Medical Oncology Department, Centre Léon-Bérard, Lyon, France
| | - Nathalie Gaspar
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
| | - Pablo Berlanga
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France.
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16
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Gultekin M, Yildiz F. In Regard to Doyen et al. Int J Radiat Oncol Biol Phys 2019; 105:1163-1164. [DOI: 10.1016/j.ijrobp.2019.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 08/26/2019] [Accepted: 09/04/2019] [Indexed: 11/16/2022]
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