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Pena-Burgos EM, De Sabando DPL, Utrilla C, Pozo-Kreilinger JJ, Sastre A, Rubio P, Escudero A, Mendiola-Sabio M, Pérez-Martínez A. First Reported Case of Malignant Ectomesenchymoma with p.Leu122Arg Mutation in MYOD1 Gene: Extensive Intra- and Extracranial Tumor in a 15-Year-Old Female. Head Neck Pathol 2023; 17:855-863. [PMID: 36913073 PMCID: PMC10514254 DOI: 10.1007/s12105-023-01542-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/08/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Ectomesenchymomas (EMs) are extremely rare neoplasms composed of malignant mesenchymal components and neuroectodermal derivatives. They are described in a wide variety of locations, with the head and neck region being one of the most frequently involved areas. EMs are usually managed as high-risk rhabdomyosarcomas and have similar outcomes. METHODS We present the case of a 15-year-old female with an EM that arose in the parapharyngeal space and extended into the intracranial space. RESULTS Histologically, the tumor presented an embryonal rhabdomyosarcomatous mesenchymal component and the neuroectodermal component was constituted by isolated ganglion cells. Next-generation sequencing (NGS) revealed a p.Leu122Arg (c.365 T > G) mutation in the MYOD1 gene, a p.Ala34Gly mutation in the CDKN2A gene, and CDK4 gene amplification. The patient was treated with chemotherapy. She died 17 months after the debut of symptoms. CONCLUSION(S) To our knowledge, this is the first reported case in English literature of an EM with this MYOD1 mutation. We suggest combining PI3K/ATK pathway inhibitors in these cases. NGS should be performed in EMs cases to detect mutations with potential treatment options.
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Affiliation(s)
- E M Pena-Burgos
- Pathology Department, La Paz University Hospital, Paseo de La Castellana, 261, 28046, Madrid, Spain.
| | | | - C Utrilla
- Radiology Department, La Paz University Hospital, Madrid, Spain
| | - J J Pozo-Kreilinger
- Pathology Department, La Paz University Hospital, Paseo de La Castellana, 261, 28046, Madrid, Spain
| | - A Sastre
- Pediatric Oncology Department, La Paz University Hospital, Madrid, Spain
| | - P Rubio
- Pediatric Oncology Department, La Paz University Hospital, Madrid, Spain
| | - A Escudero
- Pediatric Oncology Department, La Paz University Hospital, Madrid, Spain
| | - M Mendiola-Sabio
- La Paz University Hospital, Molecular Pathology and Therapeutic Targets Group, Instituto de Investigación del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - A Pérez-Martínez
- Pediatric Oncology Department, La Paz University Hospital, Madrid, Spain
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Rodriguez JD, Selleck AM, Abdel Razek AAK, Huang BY. Update on MR Imaging of Soft Tissue Tumors of Head and Neck. Magn Reson Imaging Clin N Am 2021; 30:151-198. [PMID: 34802577 DOI: 10.1016/j.mric.2021.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article reviews soft tissue tumors of the head and neck following the 2020 revision of WHO Classification of Soft Tissue and Bone Tumours. Common soft tissue tumors in the head and neck and tumors are discussed, along with newly added entities to the classification system. Salient clinical and imaging features that may allow for improved diagnostic accuracy or to narrow the imaging differential diagnosis are covered. Advanced imaging techniques are discussed, with a focus on diffusion-weighted and dynamic contrast imaging and their potential to help characterize soft tissue tumors and aid in distinguishing malignant from benign tumors.
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Affiliation(s)
- Justin D Rodriguez
- Department of Radiology, Duke University, 2301 Erwin Rd, Durham, NC 27705, USA
| | - A Morgan Selleck
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina Hospitals, 170 Manning Drive, CB 7070, Physicians Office Building, Rm G190A, Chapel Hill, NC 27599, USA
| | | | - Benjamin Y Huang
- Department of Radiology, UNC School of Medicine, 101 Manning Drive, CB#7510, Chapel Hill, NC 27599, USA.
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Bansal A, Goyal S, Goyal A, Jana M. WHO classification of soft tissue tumours 2020: An update and simplified approach for radiologists. Eur J Radiol 2021; 143:109937. [PMID: 34547634 DOI: 10.1016/j.ejrad.2021.109937] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 02/07/2023]
Abstract
The WHO classification of soft tissue tumours categorizes the lesions based on histological differentiation. In the recent fifth edition (2020), many new entities have been introduced, based on their distinct biological behaviour, genetics and morphology. With the recent advances and better understanding of molecular genetics, several novel recurrent genetic alterations have been incorporated in this edition. These may serve as reliable diagnostic and prognostic markers for various soft tissue tumours. Though predominantly a pathologist's game; the radiologists must be aware of the recent updates to contribute towards the optimal diagnosis and management of soft tissue tumours. The imaging features of the new entities have not yet been described but are expected to be explored in the coming years. We hereby present a concise review of the updates in the recent WHO classification of soft tissue tumours. We have tried to emphasize the novel molecular genetics and their surrogate immunohistochemical markers which have brought a paradigm shift in the diagnosis, therapeutics, and prognosis of soft tissue tumours. We also present simplified diagnostic algorithms to characterize soft tissue tumours based on the clinico-radiological features.
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Affiliation(s)
- Abhinav Bansal
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Surbhi Goyal
- Department of Pathology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Ankur Goyal
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Manisha Jana
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
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More Than Meets the Eye? A Cautionary Tale of Malignant Ectomesenchymoma Treated as Low-risk Orbital Rhabdomyosarcoma. J Pediatr Hematol Oncol 2021; 43:e854-e858. [PMID: 32769567 DOI: 10.1097/mph.0000000000001901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/28/2020] [Indexed: 11/26/2022]
Abstract
Malignant ectomesenchymoma (MEM) is a rare multiphenotypic tumor comprised of mesenchymal and neuroectodermal components. MEM is typically diagnosed in infants and younger children and outcomes are variable. The current approach for treating MEM includes targeting the more aggressive mesenchymal component of the tumor, which is often rhabdomyosarcoma. Here, we describe a case of an orbital tumor initially diagnosed and treated as low-risk rhabdomyosarcoma. Local failure prompting a second biopsy revealed neuronal differentiation consistent with a diagnosis of MEM. Intensifying therapy and local radiotherapy led to a long-term cure. This case offers a cautionary tale that while outcomes for MEM were similar to matched rhabdomyosarcoma cohorts when treated on conventional Intergroup Rhabdomyosarcoma Study Group (IRSG) III/IV protocols, treating MEM using a decreased intensity low-risk rhabdomyosarcoma regimen may not be sufficient.
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Satală CB, Jung I, Bara TJ, Simu P, Simu I, Vlad M, Szodorai R, Gurzu S. Primary rhabdomyosarcoma: An extremely rare and aggressive variant of male breast cancer. World J Clin Cases 2020; 8:4466-4474. [PMID: 33083405 PMCID: PMC7559662 DOI: 10.12998/wjcc.v8.i19.4466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/28/2020] [Accepted: 09/04/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Rhabdomyosarcoma (RMS) of the breast, a mesenchymal neoplasm with skeletal muscle differentiation, is an extremely rare tumour in males, with less than 30 cases published in English-language literature. We report on the first case of a male breast RMS, with an unusual ectomesenchymal/neuroectodermal component.
CASE SUMMARY A 55-year-old, previously healthy male, underwent a radical left mastectomy for an ulcerated tumour mass, occupying the breast and left anterior thoracic wall. The biopsy specimen indicated the presence of a tumour with neural origins, namely a peripheral neuroectodermal tumour (PNET). The surgical specimens identified two components. The rhabdomyosarcomatous component (over 70%) was represented by large pleomorphic cells with positivity for desmin, sarcomeric actin and myogenin. The PNET-like ectomesenchymal component, which was admixed with the RMS cells, and was also revealed during the preoperative biopsy, consisted of small cells which expressed neurofilament, neuron specific enolase and CD99. The microscopic examination, along with the immunohistochemical profile, allowed the diagnosis of an RMS, with unusual ectomesenchymal differentiation. The patient refused the postoperative oncologic therapy and died three months after surgery.
CONCLUSION In patients with RMS of the breast, the PNET-like ectomesenchymal component increases the diagnosis difficulty, especially in biopsy specimens. This differentiation can be immunohistochemically proven and might highlight the possible development of high-grade sarcoma of the breast from remnants of the embryological ectodermal layer.
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Affiliation(s)
- Cătălin Bogdan Satală
- Department of Pathology, Clinical County Emergency Hospital, Tirgu Mures 540139, Romania
| | - Ioan Jung
- Department of Pathology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Targu Mures 530149, Romania
| | - Tivadar Jr Bara
- Department of Surgery, Clinical County Emergency Hospital, Targu Mures 540136, Romania
| | - Patricia Simu
- Department of Radiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Targu Mures 530149, Romania
| | - Iunius Simu
- Department of Radiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Targu Mures 530149, Romania
| | - Madalina Vlad
- Department of Pathology, Clinical County Emergency Hospital, Targu Mures 540136, Romania
| | - Rita Szodorai
- Department of Pathology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Targu Mures 530149, Romania
| | - Simona Gurzu
- Department of Pathology, Clinical County Emergency Hospital, Targu Mures 540136, Romania
- Department of Pathology, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Targu Mures 530149, Romania
- Research Center (CCAMF), University of Medicine, Pharmacy, Sciences and Technology, Targu Mures 540139, Romania
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Mahajan S, Suri V, Sharma MC, Kedia S, Sardana H, Nakra T. Primary intracranial malignant ectomesenchymoma in an adult: Report of a rare case and review of the literature. Neuropathology 2019; 39:200-206. [PMID: 30907031 DOI: 10.1111/neup.12547] [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: 10/15/2018] [Revised: 02/05/2019] [Accepted: 02/06/2019] [Indexed: 11/30/2022]
Abstract
Malignant ectomesenchymoma (MEM) is an exceedingly rare rapidly progressing tumor of soft tissues of the central nervous system, believed to be derived from neural crest cells. The majority of cases have been observed in young children or adolescents. So far only 11 patients with intracranial manifestations (with confirmed clinicopathological data) have been documented. We report the first case of adult intracranial MEM in a 54-year-old man who presented with a 4 months history of headache and weakness of right side of the body. Magnetic resonance imaging showed a homogenously enhanced dural-based lesion in the left fronto-temporo-parietal lobe with significant perilesional edema and mass effect. No metastatic disease was identified and the lesion was grossly resected. Histopathological and immunohistochemical examination revealed mature and immature neurons and bizarre astrocytes admixed with a mesenchymal spindle cell (rhabdomyoblastic) component. Specific risk factors that contribute toward the development of MEM are unknown. Due to the scarcity of reported cases the role of adjuvant therapy is unclear.
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Affiliation(s)
- Swati Mahajan
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Vaishali Suri
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Mehar C Sharma
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Shweta Kedia
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Hardik Sardana
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Tripti Nakra
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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Kao WT, Chiang YT, Tzou KY. An Adult Paratesticular Malignant Ectomesenchymoma With Post-operative Flare-up of Lung Metastasis. Urol Case Rep 2015; 3:164-6. [PMID: 26793539 PMCID: PMC4672669 DOI: 10.1016/j.eucr.2015.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/25/2015] [Indexed: 11/20/2022] Open
Abstract
Malignant ectomesenchymoma (MEM) which is derived from the remnants of migratory neural crest cells (ectomesenchyme) is a rare and rapidly progressing tumor consisting of neuroectodermal and mesenchymal neoplastic elements. This tumor occurs mostly in children and adolescents, but rarely in adults. We report a 34-year-old male with left paratesticular malignant ectomesenchymoma who received radical orchiectomy and was followed by post-operative flare-up of lung metastasis within 2 weeks. We present the overall treatment strategies for this extremely rare tumor and related findings.
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Affiliation(s)
| | | | - Kai-Yi Tzou
- Corresponding author. Department of Urology, Taipei Medical University, Shuang Ho Hospital, No. 291 Jhongjheng Rd., Jhonghe District, New Taipei City 23561, Taiwan, ROC. Tel.: +886 2 2249 0088x8111; fax: +886 2 2249 0088x8760.
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VandenHeuvel KA, Carpentieri DF, Chen J, Fung KM, Parham DM. Ectomesenchymoma with embryonal rhabdomyosarcoma and ganglioneuroma, arising in association with benign triton tumor of the tongue. Pediatr Dev Pathol 2014; 17:226-30. [PMID: 24650353 DOI: 10.2350/14-01-1433-cr.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Soft-tissue tumors known as "triton" tumors are rare lesions containing neural tissue and skeletal muscle at varying levels of maturity and malignant potential. Benign triton tumors, also called "neuromuscular choristomas" or "neuromuscular hamartomas," consist of neural tissue containing mature skeletal muscle in intimate relationship with peripheral nerve. These tumors are rare in the head and neck in children. Ectomesenchymomas are similar tumors consisting of a malignant mesenchymal component, usually embryonal rhabdomyosarcoma, and a neuroectodermal component represented by mature ganglion cells or primitive neuroblastic/neuroectodermal foci (primitive ectomesenchymoma). Benign triton tumors have been regarded as benign, whereas ectomesenchymomas have been operationally considered to be variants of rhabdomyosarcoma. We present here a unique case that combines features of these 2 entities in a recurrent lesion on the tongue of a 35-month-old girl. This lesion raises questions about the "benign" nature of benign triton tumor and its possible relationship to ectomesenchymoma.
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Affiliation(s)
- Katherine A VandenHeuvel
- 1 Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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Altenburger DL, Wagner AS, Eslin DE, Pearl GS, Pattisapu JV. A rare case of malignant pediatric ectomesenchymoma arising from the falx cerebri. J Neurosurg Pediatr 2011; 7:94-7. [PMID: 21194292 DOI: 10.3171/2010.10.peds10261] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Malignant ectomesenchymoma is a rare tumor arising from mature ganglion cells with immature myogenous elements, with only 4 pediatric intracranial cases having been previously reported. The authors report a rare case of intracranial malignant ectomesenchymoma originating from the falx cerebri in a 10-year-old boy. The patient presented with a 2-week history of headache, nausea, and blurry vision, with mild lateral gaze diplopia. A CT scan revealed a solitary 7.2 × 3.8-cm dural-based mass that extended along the falx. No metastatic disease was identified, and the lesion was grossly resected without complication. Pathological investigation identified single and small groups of cells in a myxoid background, with polygonal or spindle-shaped cells containing eccentric nuclei and prominent nucleoli. Immunohistochemical staining of some cells was positive for smooth-muscle actin, CD99, and vimentin, whereas other cells (often process forming) were positive for S100 protein, synaptophysin, and neurofilament protein. Staining was negative for CD138, CD45, α-fetoprotein, CK AE1/3, glial fibrillary acidic protein, CK7, CK20, CD31, CD34, myoD, and desmin. Normal immunopositivity was seen for INI-1. The Ki 67 immunostaining had < 25% reactivity. The patient was treated with a sarcoma-based chemotherapy regimen and radiation to the craniospinal axis, and was found to be without recurrence or metastatic disease at 20 months.
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Affiliation(s)
- Dana L Altenburger
- Department of Pathology, Orlando Health, 83 West Columbia Street, Orlando, FL 32806, USA
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Kleinschmidt-DeMasters BK, Lovell MA, Donson AM, Wilkinson CC, Madden JR, Addo-Yobo SO, Lillehei KO, Foreman NK. Molecular array analyses of 51 pediatric tumors shows overlap between malignant intracranial ectomesenchymoma and MPNST but not medulloblastoma or atypical teratoid rhabdoid tumor. Acta Neuropathol 2007; 113:695-703. [PMID: 17431644 DOI: 10.1007/s00401-007-0210-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 02/16/2007] [Accepted: 02/17/2007] [Indexed: 10/23/2022]
Abstract
Gene microarray has been used to identify prognostic markers and genes of interest for therapeutic targets; a less common use is to show possible histogenetic relationships between rare tumor types and more common neoplasms. Intracranial malignant ectomesenchymoma (MEM) is a pediatric tumor postulated to arise from neural crest cells that contain divergent neuroectodermal and mesenchymal tissues, principally mature ganglion cells and rhabdomyosarcoma (RMS). We investigated a case of MEM by molecular, cytogenetic, and gene array analyses and compared results with our previously unpublished series of 51 pediatric tumors including conventional RMS, Ewing sarcoma (EWS), medulloblastoma (MED), atypical teratoid rhabdoid tumor (ATRT), and malignant peripheral nerve sheath tumor (MPNST); the latter is a sarcoma also with potential for divergent differentiation. Standard cytogenetic analyses and RT-PCR testing for the classic gene rearrangements seen in RMS [t(2;13)-PAX3/FKHR] and EWS ([t(11;22) & t(21;22)-EWS/FLI-1 & EWS/ERG), were used for characterization of the MEM, with gene expression microarray analyses on all tumor types. Gene rearrangement studies were negative in MEM. Gene expression microarray analyses showed tight clustering of the MEM with the MPNST (n = 2), but divergence from other pediatric tumors. MEM and MPNST both showed complex karyotypes, but without diagnostic translocations. Despite the presence of malignant skeletal muscle differentiation in the MEM, gene array testing showed no overlap with RMS, MED, or ATRT, but rather with MPNST. This suggests a common stem cell origin or embryonic gene recapitulation for these tumors and provides novel insights into their underlying biology.
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Affiliation(s)
- B K Kleinschmidt-DeMasters
- University of Colorado at Denver and Health Science Center, 4200 East Ninth Avenue, B-216, Denver, CO 80262, USA.
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Cergnul M, La Rosa S, Bandera M, Battaglia P, Bignami M, Castelnuovo P, Capella C, Pinotti G. Malignant ectomesenchymoma of the nasal cavity. Lancet Oncol 2007; 8:358-60. [PMID: 17395109 DOI: 10.1016/s1470-2045(07)70105-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
February 2005. Case report of a 10-month-old boy with a large tumor located in the pineal gland, consisting of glia, ganglion cells, pigmented neuroepithelium and striated muscle, without immature components. The combination of neuroectodermal and mesenchymal constituents includes entities as pineal anlage tumor (melanotic neuroectodermal tumor of infancy, MNTI), ectomesenchymoma, medullomyoblastoma, and teratoma in the differential diagnosis. Lack of immature elements in this case, however, eliminates ectomesenchymoma and medullomyoblastoma from the differential diagnosis. Retinal anlage tumors, to be considered as MNTI at the site of the pineal gland, usually harbor immature components as well. Therefore, the present case does not match strict criteria of any of the categories mentioned and therefore we have designated it as a "pineal anlage tumor (without immature components)".
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Holak HM, Reinecke-Lüthge A, Holak NH, Schier B, Holak SA. Fibröses Histiozytom der Orbita. Zwei Kasuistiken eines seltenen Tumors. SPEKTRUM DER AUGENHEILKUNDE 2005. [DOI: 10.1007/bf03163464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Oppenheimer O, Athanasian E, Meyers P, Antonescu CR, Gorlick R. Malignant ectomesenchymoma in the wrist of a child: case report and review of the literature. Int J Surg Pathol 2005; 13:113-6. [PMID: 15735865 DOI: 10.1177/106689690501300117] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Malignant ectomesenchymomas, rare and potentially aggressive tumors, occur in children and exhibit mesenchymal and neuroectodermal components. This report describes the first patient diagnosed with a malignant ectomesenchymoma of the hand. The patient was a 17-month-old male who developed a hypothenar mass on his left hand that was surgically excised. Microscopic evaluation revealed ganglioneuroblastic, rhabdomyosarcomatous, and chondrosarcomatous elements. Following excisional biopsy he was treated with cyclophosphamide, doxorubicin, vincristine, ifosfamide, and etoposide. After 3 courses of chemotherapy the patient had a wide reexcision with no residual tumor. The patient is 4 years from diagnosis, without evidence of disease.
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Affiliation(s)
- Orit Oppenheimer
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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