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Bansal R, Bhojwani D, Sun BF, Sawardekar S, Wayne AS, Ouassil H, Gupte C, Marcelino C, Gonzalez Anaya MJ, Luna N, Peterson BS. Progression of brain injuries associated with methotrexate chemotherapy in childhood acute lymphoblastic leukemia. Pediatr Res 2024:10.1038/s41390-024-03351-9. [PMID: 38951657 DOI: 10.1038/s41390-024-03351-9] [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: 09/13/2023] [Revised: 01/18/2024] [Accepted: 06/07/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Brain bases and progression of methotrexate-associated neurotoxicity and cognitive disturbances remain unknown. We tested whether brain abnormalities worsen in proportion to intrathecal methotrexate(IT-MTX) doses. METHODS In this prospective, longitudinal study, we recruited 19 patients with newly diagnosed acute lymphoblastic leukemia 4-to-20 years of age and 20 matched controls. We collected MRI and neuropsychological assessments at a pre-methotrexate baseline and at week 9, week 22, and year 1 during treatment. RESULTS Patients had baseline abnormalities in cortical and subcortical gray matter(GM), white matter(WM) volumes and microstructure, regional cerebral blood flow, and neuronal density. Abnormalities of GM, blood flow, and metabolites worsened in direct proportions to IT-MTX doses. WM abnormalities persisted until week 22 but normalized by year 1. Brain injuries were localized to dorsal and ventral attentional and frontoparietal cognitive networks. Patients had cognitive deficits at baseline that persisted at 1-year follow-up. CONCLUSIONS Baseline abnormalities are likely a consequence of neuroinflammation and oxidative stress. Baseline abnormalities in WM microstructure and volumes, and blood flow persisted until week 22 but normalized by year 1, likely due to treatment and its effects on reducing inflammation. The cytotoxic effects of IT-MTX, however, likely contributed to continued, progressive cortical thinning and reductions in neuronal density, thereby contributing to enduring cognitive deficits. IMPACT Brain abnormalities at a pre-methotrexate baseline likely are due to acute illness. The cytotoxic effects of intrathecal MTX contribute to progressive cortical thinning, reductions in neuronal density, and enduring cognitive deficits. Baseline white matter abnormalities may have normalized via methotrexate treatment and decreasing neuroinflammation. Corticosteroid and leucovorin conferred neuroprotective effects. Our findings suggest that the administration of neuroprotective and anti-inflammatory agents should be considered even earlier than they are currently administered. The neuroprotective effects of leucovorin suggest that strategies may be developed that extend the duration of this intervention or adapt it for use in standard risk patients.
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Affiliation(s)
- Ravi Bansal
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA.
| | - Deepa Bhojwani
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Bernice F Sun
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Siddhant Sawardekar
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Alan S Wayne
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Hannah Ouassil
- College of Letters, Arts and Sciences, University of Southern California, Los Angeles, CA, USA
| | - Chaitanya Gupte
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Courtney Marcelino
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Maria J Gonzalez Anaya
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Natalia Luna
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Bradley S Peterson
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Institute for the Developing Mind, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Vuotto SC, Wang M, Okcu MF, Bowers DC, Ullrich NJ, Ness KK, Li C, Srivastava DK, Howell RM, Gibson TM, Leisenring WM, Oeffinger KC, Robison LL, Armstrong GT, Krull KR, Brinkman TM. Neurologic morbidity and functional independence in adult survivors of childhood cancer. Ann Clin Transl Neurol 2024; 11:291-301. [PMID: 38013658 PMCID: PMC10863908 DOI: 10.1002/acn3.51951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/02/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE To examine associations between neurologic late effects and attainment of independence in adult survivors of childhood cancer treated with central nervous system (CNS)-directed therapies. METHODS A total of 7881 survivors treated with cranial radiation therapy (n = 4051; CRT) and/or intrathecal methotrexate (n = 4193; IT MTX) ([CNS-treated]; median age [range] = 25.5 years [18-48]; time since diagnosis = 17.7 years [6.8-30.2]) and 8039 without CNS-directed therapy reported neurologic conditions including stroke, seizure, neurosensory deficits, focal neurologic dysfunction, and migraines/severe headaches. Functional independence was assessed using latent class analysis with multiple indicators (independent living, assistance with routine and personal care needs, ability to work/attend school, attainment of driver's license, marital/partner status). Multivariable regression models, adjusted for age, sex, race/ethnicity, and chronic health conditions, estimated odds ratios (OR) or relative risks (RR) for associations between neurologic morbidity, functional independence, and emotional distress. RESULTS Among CNS-treated survivors, three classes of independence were identified: (1) moderately independent, never married, and non-independent living (78.7%); (2) moderately independent, unable to drive (15.6%); and (3) non-independent (5.7%). In contrast to 50% of non-CNS-treated survivors and 60% of siblings, a fourth fully independent class of CNS-treated survivors was not identified. History of stroke (OR = 2.50, 95% CI: 1.70-3.68), seizure (OR = 9.70, 95% CI: 7.37-12.8), neurosensory deficits (OR = 2.67, 95% CI: 2.16-3.31), and focal neurologic dysfunction (OR = 3.05, 95% CI: 2.40-3.88) were associated with non-independence among CNS-treated survivors. Non-independence was associated with emotional distress symptoms. INTERPRETATION CNS-treated survivors do not attain full independence comparable to non-CNS-treated survivors or siblings. Interventions to promote independence may be beneficial for survivors with treatment-related neurological sequalae.
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Affiliation(s)
| | - Mingjuan Wang
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - M. Fatih Okcu
- Texas Children's Hospital, Baylor College of MedicineHoustonTexasUSA
| | | | - Nicole J. Ullrich
- Dana‐Farber/Boston Children's Cancer and Blood Disorders CenterBostonMassachusettsUSA
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Chenghong Li
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Deo Kumar Srivastava
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | | | - Todd M. Gibson
- National Cancer InstituteDivision of Cancer Epidemiology & GeneticsBethesdaMarylandUSA
| | | | - Kevin C. Oeffinger
- Duke Univeristy School of MedicineDuke Cancer InstituteDurhamNorth CarolinaUSA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Kevin R. Krull
- Department of Psychology & Biobehavioral SciencesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Tara M. Brinkman
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
- Department of Psychology & Biobehavioral SciencesSt. Jude Children's Research HospitalMemphisTennesseeUSA
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de Ville de Goyet M, Kicinski M, Suciu S, Vandecruys E, Uyttebroeck A, Ferster A, Freycon C, Plat G, Thomas C, Barbati M, Dresse MF, Paillard C, Pluchart C, Simon P, Chantrain C, Minckes O, van der Werff Ten Bosch J, Bertrand Y, Rohrlich P, Millot F, Paulus R, Benoit Y, Piette C. Long-term neurotoxicity among childhood acute lymphoblastic leukaemia survivors enrolled between 1971 and 1998 in EORTC Children Leukemia Group studies. Discov Oncol 2024; 15:20. [PMID: 38285235 PMCID: PMC10825101 DOI: 10.1007/s12672-024-00869-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/19/2024] [Indexed: 01/30/2024] Open
Abstract
Survival after childhood acute lymphoblastic leukemia (ALL) has increased over the last 40 years with an overall survival above 90%. Survivors may experience neurological late effects secondary to chemotherapy and radiotherapy. This observational retrospective study evaluated the cumulative incidence of neurological late effects among 890 childhood ALL survivors treated in EORTC CLG trials (58741, 58831/2 and 58881) between 1971 and 1998. Median follow-up was 19 years and interquartile range of the follow-up was 15-22 years. At 20 years from the end of treatment, approximately 66% of patients from the 58741 trial (accrual time: 1971-1978) and approximately 15% from the more recent trials had cognitive disturbance grade 1 or higher. Cumulative incidences at 20 years from treatment end of seizures, stroke and leukoencephalopathy were respectively 45%, 16% and 62% in study 58741, 13%, 2% and 5% in study 58831/2, and 8%, 2% and 3% in study 58881. Patients who were 10-17 years of age at diagnosis had a higher incidence of stroke and leukoencephalopathy as compared to those less than 6 years of age. Noteworthy, all neurological late effects continued to occur beyond 5 years after end of treatment. This retrospective study highlights the frequency of neurological late effects in survivors of childhood ALL. With the increase of the overall survival of ALL patients, the role and potential benefit of longitudinal neurological screening should be evaluated in further studies as these neurological late effects become an important public health challenge. This study is part of the larger EORTC CLG 58 Late Adverse Effects (LAE) study (ClinicalTrials.gov Identifier NCT01298388, date of registration February 16, 2011).
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Affiliation(s)
- Maëlle de Ville de Goyet
- Department of Paediatric Haematology-Oncology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | | | - Els Vandecruys
- Department of Paediatric Haematology-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Anne Uyttebroeck
- Department of Paediatric Haematology-Oncology, University Hospital Leuven, Louvain, Belgium
| | - Alina Ferster
- Department of Haemato Oncology, HUDERF (ULB), Brussels, Belgium
| | - Claire Freycon
- Department of Paediatric Haematology-Oncology, CHU Grenoble, Grenoble, France
| | - Geneviève Plat
- Department of Haematology, CHU Toulouse, Toulouse, France
| | | | - Mélissa Barbati
- Department of Paediatric Haematology-Oncology, CHRU Lille, Lille, France
| | - Marie-Françoise Dresse
- Department of Paediatrics, University Hospital Liège and University of Liège, Liège, Belgium
| | - Catherine Paillard
- Department of Paediatric Haematology-Oncology, CHRU Strasbourg, Strasbourg, France
| | - Claire Pluchart
- Department of Paediatric Haematology and Oncology, CHU Reims, Reims, France
| | | | | | - Odile Minckes
- Department of Paediatric Haematology-Oncology, CHU Caen, Caen, France
| | | | - Yves Bertrand
- Department of Paediatric Onco-Haematology, Lyon University Hospital, Hospices Civils de Lyon and, Université Claude Bernard Lyon, Lyon, France
| | - Pierre Rohrlich
- Division of Paediatric Haematology-Oncology, CHU Nice, Nice, France
| | - Frederic Millot
- Department of Paediatric Haematology-Oncology, CHU Poitiers, Poitiers, France
| | | | - Yves Benoit
- Department of Paediatric Haematology-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Caroline Piette
- Department of Paediatrics, University Hospital Liège and University of Liège, Liège, Belgium.
- Service de Pédiatrie, CHU Liège, Avenue de l'Hôpital 1, 4000 Liège, Belgium.
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Nordhjem BJT, Tjørnlund M, Thomsen BL, Hjerming M, Kjær TW, Pappot H, Hjalgrim LL. Protocol for a prospective, longitudinal study of cognitive impairment in young patients with cancer: a multidisciplinary neuroscience approach (MyBrain). BMJ Open 2023; 13:e070534. [PMID: 37202143 DOI: 10.1136/bmjopen-2022-070534] [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] [Indexed: 05/20/2023] Open
Abstract
INTRODUCTION The aim of this research is to investigate young cancer patients' cognitive functioning and the underlying neurobiological mechanisms when cognitive functions are impaired. The MyBrain protocol is a multidisciplinary study that investigates cancer-related cognitive impairment in children, adolescents and young adults, combining neuropsychology, cognitive neuroscience and cellular neuroscience. The study is exploratory with a wide focus on trajectories of cognitive functions from diagnosis to the end of treatment and into survivorship. METHODS AND ANALYSIS Prospective longitudinal study including patients diagnosed with non-brain cancers at age 7-29 years. Each patient is paired with a control matched on age and social circle. PRIMARY OBJECTIVE Evaluation of neurocognitive function over time. SECONDARY OBJECTIVES Evaluation of self-perceived quality of life and fatigue, P300 in an electroencephalography (EEG) oddball paradigm, power spectrum in resting state EEG, serum and cerebrospinal fluid levels of biomarkers of neuronal damage, neuroplasticity, proinflammatory and anti-inflammatory markers and their association with cognitive function. ETHICS AND DISSEMINATION The study is approved by the Regional Ethics Committee for the Capital Region of Denmark (no. H-21028495), and the Danish Data Protection Agency (no. P-2021-473). Results are expected to guide future interventions to prevent brain damage and support patients with cognitive difficulties. TRIAL REGISTRATION NUMBER The article is registered at clinicaltrials.gov NCT05840575 (https://clinicaltrials.gov/ct2/show/NCT05840575).
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Affiliation(s)
| | - Morten Tjørnlund
- Center for Rehabilitation of Brain Injury, University of Copenhagen, Copenhagen, Denmark
| | - Birthe Lykke Thomsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Maiken Hjerming
- Department of Haematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Helle Pappot
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lisa Lyngsie Hjalgrim
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Aleksonis HA, Krishnamurthy LC, King TZ. White matter hyperintensity volumes are related to processing speed in long-term survivors of childhood cerebellar tumors. J Neurooncol 2021; 154:63-72. [PMID: 34231115 DOI: 10.1007/s11060-021-03799-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/25/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Across several clinical populations, higher white matter hyperintensity (WMH) burden is consistently associated with decreases in cognitive performance, especially processing speed. Research of childhood cancer survivors has not utilized WMH quantification methodology to better understand the impact of WMH burden and its relationship with core cognitive skills. The present study aimed to quantify WMH volumes in a sample of long-term survivors of childhood cerebellar tumor and investigate the relationships with performance on a measure of oral processing speed. To further explore brain-behavior relationships, multivariate sparse canonical correlations was employed to identify WMH areas that predict processing speed performance. METHODS Thirty-five survivors and 56 healthy controls underwent neuroimaging and completed a measure of oral processing speed. The survivor group was further divided based on treatment (i.e., chemoradiation therapy (n = 20) vs. surgery only (n = 15)) to better understand the impact of treatment. RESULTS Survivors, and especially those treated with chemoradiation therapy, showed higher total WMH volumes and slower processing speed. Higher total WMH volumes were significantly associated with poorer processing speed (r = - 0.492, p = 0.003). Multivariate brain-behavior relationships revealed that periventricular WMHs were significantly associated with slower processing speed performance (p < 0.05). CONCLUSION Results exemplify that long-term survivors treated with and without chemoradiation therapy are at increased risk of developing higher WMH volumes compared to healthy peers. In addition, processing speed was robustly shown to be related to periventricular WMHs using an automated neuroimaging pipeline. This methodology to monitor WMH burden has the potential to be implemented efficiently with routine clinical neuroimaging of cancer survivors.
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Affiliation(s)
- Holly A Aleksonis
- Department of Psychology and the Neuroscience Institute, Georgia State University, Urban Life Building, 11th Floor, 140 Decatur St, Atlanta, GA, 30303, USA
| | - Lisa C Krishnamurthy
- Center for Visual and Neurocognitive Rehabilitation, Atlanta Veteran's Affairs Medical Center, Decatur, GA, USA
- Department of Physics and Astronomy, Georgia State University, Atlanta, GA, USA
| | - Tricia Z King
- Department of Psychology and the Neuroscience Institute, Georgia State University, Urban Life Building, 11th Floor, 140 Decatur St, Atlanta, GA, 30303, USA.
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Jacola LM, Partanen M, Lemiere J, Hudson MM, Thomas S. Assessment and Monitoring of Neurocognitive Function in Pediatric Cancer. J Clin Oncol 2021; 39:1696-1704. [PMID: 33886364 DOI: 10.1200/jco.20.02444] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Marita Partanen
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | | | - Sophie Thomas
- Nottingham Children's Hospital, Nottingham, United Kingdom
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Rijmenams I, Moechars D, Uyttebroeck A, Radwan A, Blommaert J, Deprez S, Sunaert S, Segers H, Gillebert CR, Lemiere J, Sleurs C. Age- and Intravenous Methotrexate-Associated Leukoencephalopathy and Its Neurological Impact in Pediatric Patients with Lymphoblastic Leukemia. Cancers (Basel) 2021; 13:cancers13081939. [PMID: 33923795 PMCID: PMC8073318 DOI: 10.3390/cancers13081939] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 12/04/2022] Open
Abstract
Simple Summary In this study, we investigated standardized post-chemotherapy magnetic resonance (MR) scans for leukoencephalopathy and patient- and treatment-related risk factors in childhood leukemia patients. As prevalence numbers are limited, our study provides the required estimations for this population. Furthermore, we demonstrate that younger patients might be more at-risk for development of leukoencephalopathy (LE), and that a higher intravenous methotrexate (IV-MTX) dose has a cumulative toxic effect, while the number of intrathecal administrations was not significantly associated with the extent of LE. This can suggest we should modify chemotherapeutic treatment regimens by decreasing the number of IV-MTX applications, with special attention for younger patients. Abstract Methotrexate (MTX) is associated with leukoencephalopathy (LE) in children treated for lymphoblastic leukemia/lymphoma (ALL/LBL). However, large-scale studies with systematic MR acquisition and quantitative volumetric lesion information remain limited. Hence, the prevalence of lesion burdens and the potential risk factors of LE in this population are still inconclusive. FLAIR-MRI scans were acquired at the end of treatment in children who were treated for ALL/LBL, which were quantitatively analyzed for LE. Voxels were assigned to the lesion segmentation if indicated by two raters. Logistic and linear regression models were used to test whether lesion presence and size were predicted by risk factors such as age at diagnosis, gender, intrathecal (IT-) or intravenous (IV-)MTX dose, CNS invasion, and acute neurological events. Patients with a pre-existing neurological condition or low-quality MR scan were excluded from the analyses. Of the 129 patients, ten (8%) suffered from CNS invasion. Chemotherapy-associated neurological events were observed in 13 patients (10%) during therapy, and 68 patients (53%) showed LE post-treatment. LE was more frequent in cases of lower age and higher cumulative IV-MTX doses, while the extent of LE and neurological symptoms were associated only with IV-MTX doses. Neurological events were not significantly associated with LE, even though symptomatic patients demonstrated a higher ratio of LE (n = 9/13) than asymptomatic patients (n = 59/116). This study suggests leukoencephalopathy frequently occurs in both symptomatic and asymptomatic leukemia patients. Younger children and patients treated with higher cumulative IV-MTX doses might need more regular screening for early detection and follow-up of associated sequelae.
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Affiliation(s)
- Ilona Rijmenams
- Department of Brain and Cognition, KU Leuven, 3000 Leuven, Belgium; (I.R.); (D.M.); (C.R.G.)
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
| | - Daan Moechars
- Department of Brain and Cognition, KU Leuven, 3000 Leuven, Belgium; (I.R.); (D.M.); (C.R.G.)
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
| | - Anne Uyttebroeck
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
| | - Ahmed Radwan
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Jeroen Blommaert
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Gynaecological Oncology, KU Leuven, 3000 Leuven, Belgium
| | - Sabine Deprez
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Stefan Sunaert
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Heidi Segers
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
| | - Céline R. Gillebert
- Department of Brain and Cognition, KU Leuven, 3000 Leuven, Belgium; (I.R.); (D.M.); (C.R.G.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
| | - Jurgen Lemiere
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
| | - Charlotte Sleurs
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Correspondence:
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